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SAN JOAQUIN COUNTY ENV'IRONMENTAL HEALTH DEPARTMENT <br /> E—l"', <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID III SERVICE REQUEST# <br /> Serw-iZl 0/2 <br /> OWNER I OPERATOR <br /> CHECK If <br /> FACILITY NAME -v ron <br /> SITE ADD SS Street Number �owrn 4t, Avnke-, Fmanfeect q5,33(o <br /> Oir#020as P <br /> Hror A=ADDRESS (if Diftforit from Site Address) <br /> 0 QA)64- &anNamr ion k2d <br /> CITYzip <br /> 00 <br /> PH00NE#1 FAT, APk LAND Use APPucATjoN <br /> (qzf) <br /> PHONE#2 EXT. SOS DISTRICT LocAnoN 6;OF <br /> ................. CONTRACTOR SERVICE RE'QUESTOR ------------- <br /> REQUESTOR <br /> R ij,I CHECK If BILLING Mages <br /> BUSINEss NAME } PHONE <br /> ev- I <br /> HOME or MAwNoozADDRE� t� FAx#,ef L, wvwJA)Lg(& I <br /> & <br /> CITY STATE op zip vk"A ecit V 1(, <br /> BILLING ACKNOWLEDGEMENI: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site an&or project specific ENVtRONMFNTAt.,HLAI.Tli DrPARTMLN I 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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> CouNI'Y Ordinance Codes,Siandar a ,�TArr and FFDt-RAI*s, <br /> I �Z <br /> APPLICANT'S SIGNATURE:/Z.,&CA,( C#� DAi F.- <br /> % 2 <br /> PRO PO4TI I BUSINE,%OWNERE] OPFRATOR/M%NAGf"p 0 OTHER Am aomzEo AGExTA <br /> 1f1PLICAN-T is nal the proo <br /> f of authorization to sign is required Title <br /> AUTHQRIZATION 10 REL ASE INFORMATION: 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 andor criviromricritall'site assessment <br /> informwikin to the SAN JOAQUIN COUNTY ENVIRONMENTAL HVALTIt DFPAPTMLNT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> Ty PE C-0'c( <i�+A rq- of 1( ft ce4,4— <br /> Of!�RVICE REQUESTED: <br /> HEGt,-7itNEW1 <br /> APR, 2 4 2015 <br /> ............. ............... 41*1-%Orto�rA, <br /> AccEPTEo By. EMPLOYEE#: IN- V <br /> Asslat4eo TO: EmpwyEe DATE: <br /> Date Service Completed (if already completed): SERVICE CODE' P I E: <br /> Fee Amount.- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHL?48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 712 003 V1J <br />