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• <br /> SAN JOAQUIN COUNTY]ENVIRONMENTAL ALTTiDEPART <br /> ' SERVICE REQTJEST <br /> Type of Business Or property FACILITY ID# <br /> SERVICE REQUEST# I <br /> uo <br /> HECK 1 <br /> «. C of BILLING•ADDRESS� <br /> 4 QV'NEIL/OPEFtATOR <br /> \art kil'At l�ir�(lY}tiE I <br /> �:. E�Zlcod.$ITIS Aod��ss '[� - �► �' 1.�1 '' Cit I <br /> ..Street Numb D o Stree ame I <br /> At GDO 5 y <br /> WQ�IIE 171 MAILING ADDRESS (If Rifferentfrom Site Address) � �5� 5 e m <br /> ,i ,. ': Street Number Z <br /> .: .� <br /> STATE IP j <br /> CiTYr' �. . 94538 <br /> Ft` <br /> asp:,•d:`k�'�":t ` • LAND USE APPLICATION#� <br /> t <br /> NE:#1 �L y <br /> LOCATION CODE <br /> BOS Dtsrwcr <br /> m EXT. <br /> CO1'�RA <br /> TOR/SERVICE REQUESTER <br /> 4 <br /> DRESS <br /> { CHECK If BILLING AD <br /> 3�RE�SIUESTOR <br /> , <br /> B1�SINl;SS�IAIVIE x <br /> 9 <br /> PN�O/NE <br /> ,,�(i ♦i-{�•.:.�.#*y,:lt'.::.V' ,, FAX# /^ ! <br /> r AILING} DDRE5S <br /> �` •IvMEp Ivl - — - <br /> . •. ��'� -`",i: ., :;..: -- - STAT ZIP <br /> t E <br /> T SO rCNR�J.EDGE1kIENT: I, the undersigned'property <br /> or business owner, operator or authorized agent of same, <br /> aclaipwledge that all site and/or p�o�ect specific ENVIRONMENTAL HEALTH DF,F'ARTMBNT hourly charges associated with this project or <br /> activa . well be;billedto me or:iny business as identified-onithis.forrn <br /> a with all SAN JOAQUIN <br /> F� Chi t I hava�, re tired this-application and that the work to be performed will be done inaccordance <br /> also.certify p STt1TB axed.FEDERAL.la <br /> Q, ,pt dingnc$Goy Stan / ws. — <br /> -%,SIGN •' .,. ,.. - ---- - --- <br /> x I. <br /> ry' ` J OPERA`rOIt 1, 1A <br /> . OTHER AUTHORIZt3D AGENT <br /> 1R0>&RTY/BUSINESS OwNER=I , <br /> W. <br /> jf.,41�PLICAN�' not the BILLINGP,lRTY proof of authorization to sagn is required Ttrte <br /> _ <br /> • .-w ..s-.�-.. v..rL-..... �- ._ - <br /> t3N Wlian appgoablllL7Lthe owner or operator of fht pro er locatt d at the <br /> O _^ - _ _ �� <br /> .�� tL- t otecIuu�adata angor .envuonmenta77site assessment <br /> � <br /> tyre ere base o any.:ands.. z ts� g <br /> E as soon.as itis available and at the same.time itis <br /> =1rifOYin�ttlon tdathe-SAr1 <br /> son",G'DUNTY ENVIFtONAdENTAZ IiSAi.TH DEPARTMW_ <br /> ,,s :w <br /> tprb de til zti :bt m ze re ent t(ve - <br /> '-� 4 <br /> YPEF-$ERVICIa�EQtifSTED' <br /> 44-d DINM [ Ivo <br /> t <br /> , <br /> N�bA IN C <br /> FltA V 1?p E OUN <br /> FdY)EPAR7gL <br /> �+ r fi tir -s k <br /> .x ,�n •' ,. .' EMPLOYE_ <br /> DATE: l <br /> r <br /> 'EMP ' <br /> V EYE <br /> P1 <br /> SERVICE CODE <br /> bite S#rvice Completed (if alrea,ycomplieted) <br /> P ayment Date <br /> 3 Y Amount Pahl . 3 <br /> n:. >7 � heck Received.By <br /> go,W gill- <br /> yy urrnetlt'7ipe <br />