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I <br />SAN JOAQUIN CdbTX ENN onnNwAL HEAIaTH.DEP <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />�ikS 51`{ i�oj <br />FA0004S147 5koo 4431( <br />OWNER I OPERATOR �y <br />(�-• iLJ�i <br />CNOKifBILLING ADDRESS� <br />FACILITY NAME <br />ASSIGNED TO' EMPLOYEEM DATE: <br />SITE ADDRESS . r q (Q <br />( <br />SERVICE CODE: (Gt g <br />S-I-� <br />, 'I!j 4-e L qs3 / (P <br />StreetNumbar <br />irectlen <br />C hack # <br />etre aCity <br />Zip Cod <br />HomrI or MAILING ADDRESS of Different from Site Address) <br />' <br />StreetNumper Street Name <br />CITY <br />STATE ZIP <br />PHONEtH ExT <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 T <br />SOS DISTRICT <br />LOCATION CODE <br />f } <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REwESTOR S j t „ , f CHECKif BILLING ADORESS� <br />cSZi�VcC�2 S-{•ct�to�1 � � L,(�-�{,`t'U- vBuskessNAME a PHO -n - <br />HONE or MAILING ADDRESS FAX# <br />VL14, AL <br />CITY ®� S•fATE LlA, ZIP J <br />BILLII`IG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authoriztd agent of same, <br />acknowledge that all site andlor project specific ENVIftONia.Nl'AL HEALTH DEPARTN NT hourly charges assoziatcd with this proj00 <br />or activity will be billed to me or my business as identified = this form. <br />I also certify that I have prepared this application and that the work to bo performed will be done in accordance with all SAT; JOAQUIN r. <br />COUNTY Ordinance Codes, Standards, STATE and FliDBRAL laws. <br />A.$FLICAI'3"1''S SIGNATUR$: ,��. � �.+Li.-. �. I,i.�.-� � DATE: <br />PRoP m-ryI Bassx=OwN1ERM OPERAToniMANACER ❑ O AUTHoR=Ar-r-1T � (1:1, IJQ� cordivt�ti-tl�/ <br />if APPrjCwT is nat the S1E[.M PARTE` proof of authorization to sign is required Tarte I <br />AMOit1rZA'I ION TO It.F�I.EASE nyFURM46TION: Where applicable, I, the owner or operator of floe properly located at the i <br />above site address, hereby authorize the release of. any and all results, geotechnical data andlor cnviro=entaUsitc assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONNIE*TTAL HAALTH DEPARTMENT as soon as it is available and at the same time it is � <br />TyrmrAPA to mF hr my YmreSentntive <br />TYPE OF SERVICE REQUESTED: UIS T 1245�1--/ T <br />- <br />CoMMENYS: t�Ut(V " 6V1 Sly' �L mbX'Pw <br />&A� 1v " <br />IIL ib`"L t1 iw, KoL1tx'*1Z <br />V,% .iv-ek J <br />ACCEPMSY: EMPLOYEE#: 032{ DATE: <br />J0/12/05 <br />ASSIGNED TO' EMPLOYEEM DATE: <br />1D 112,166 <br />Date S.ervlce Completed If already completed): <br />SERVICE CODE: (Gt g <br />PIE: 2 3 0g <br />Fee Amount: .. Z" j q, 0 o amount Paid � 0 O <br />Payment Date ( O /1230,15 <br />Payment Type Invoice # <br />C hack # <br />((79 3 <br />Received By: <br />THD 48.02.025 P�Y�� (Golden Rod) <br />REVISED 11117!2003 RC^C,vE© <br />OCT 1 2005 <br />SAN JOAQUIN COUNN <br />ENVIRONMENTAL <br />H�.TH DEPARTMENT <br />