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Ll <br />SAN JOAQUIN COUN'T'Y ENVIRONMPNI'AL 1IFAuni DEPARTMENT <br />SERVICE REQUEST <br />T pe of Businessor Property SER ICE REQUEST# <br />1, PC <br />BUSINESS NAm <br />OWNERIOPERATOR <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />Ctircx If <br />SERVICE CODE: <br />CITY <br />II II SITE ADDIl V <br />RESS <br />.............: <br />Payment Date <br />je� <br />Payment Type <br />Received By: <br />HOME or �Altliw ADDRESS (It Different from Site Address) <br />1 <br />110 Iv III <br />CITY <br />STATE zip <br />71 4R�Z -S9 <br />LAND Use APPLICATION 0 <br />K LW4 F�A <br />W MIN <br />LOCAT]ON COOE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Co 0 0 <br />1, PC <br />BUSINESS NAm <br />PHONE # ExT. <br />HOME or MAILING ADDRESS <br />Date Service Completed (it already completed): <br />SERVICE CODE: <br />CITY <br />STATE zl� <br />.............: <br />Payment Date <br />BILGING A!CK&QW1 !El& MEN][ 1, the undersigned property or business owner, operator or authorized agent of same, <br />E <br />acknowledge that all site and/or project specific ENVIRONMENTAI. Fit-,Aurti DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Cocles, SlandardS, STATE and FrDERArjeews.14 <br />APPUCAWS SIGNA-fURE: <br />pill <br />PROPERTY/ BUSINESS 0 -Ill OPE11i MANAGF0 R OTtIERAUTHORIZEDAGENT'o xa, <br />ffAPPLICANTiSnot li � rGPA8 <br />�_ GPAR proof ofauthorization to sign Is required Title <br />AVTHQRfM110N TO RELEASE INFORMA_TIQN: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMrNTAI., Ht-.ALTti DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Pll Si r4—fo-en— <br />ACCEPTED BY: EMPLOYEE <br />ASSIGNED TO: N N�EMPLOYEE#: ������ <br />I <br />Date Service Completed (it already completed): <br />SERVICE CODE: <br />.............: <br />Payment Date <br />je� <br />Payment Type <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />up <br />