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SAN JOAQUIN COUNTY ENVIRONMENTAL HEA..I.A , EPARTMENT <br />SERVICE REQUEST <br />Typp of Business or Property FACILITY 1D # SERVICE REQUEST # <br />/O <br />F=ACILITY <br />SITE <br />HOME Or MAILINt3 AockESS (If Different from Site Address) <br />CITY <br />PHONE#1 Exr. qPN # <br />( 1 <br />PHONE #2 EXT. <br />CHECK if <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT II LOCATION CODE, <br />CONTRACTOR/SERV-1t:1161 tcWUL,./N,'1-"K n <br />REQUESTO CHECK If BILLIN,ADDREs3 L.1 <br />/ a3&fl.i1[/ Exi. <br />BUSINESS NAME PHONF 7i /] <br />Home Or MAILI ES FAX 0 ID <br />37/ <br />CITY0 L65 STATE ZIP q5 <br />W <br />BILLING ACiCNOWLEDGU : I, the undersigned property or business owner, operator or authorized agent of sane, <br />acknowledge that: all site and/or project specific ENVIRONMiNTAL 1"I73AI.Ti-1 DEPARTMENT hourly Charges associated with this prOjcct <br />or Activity will be billed to me or ttty business as identi#ied 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 a]I SAN JOAQUrN <br />COUNTY Ordinance Codes, Standards, STArt: and FrDERAL <br />APPLICANT'S SIGNATURE: r� DATr.: <br />PROPERTY / BUSINt:Ss OWNCR OPF,RATOR ANAcrm GI OTHf:it A LITHORI%Iii) AGENT Q <br />If AnP/JCA NT R,S not thN /3/I.l./Nr 1'dR77, progf of aufhorkation to sign is required Title <br />IA UICHORIZA TON TO RELI' A51 IN'TORMATIQN_: 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, gcotcehnical data and/or cnvironmenta.1/site assessment <br />information to the SAN lOAQUTM COIJNTY ENViRONMF'NTAi. Hi3ALTT•r DIEPARTMENT as soon AS it is available and at the same time it is <br />provided to me or my representa.tive. <br />TYPE OF SERVICE REQUESTEo: U !� 7 <br />r—i i <br />AY MEN <br />COMMENTS: <br />R <br />21 2011 <br />NOV <br />CO AL <br />,DAQ1J1 <br />W-RpEFAR ENS <br />ACCEpTFO i3Y: L-0 CA-) <br />EMPLOYEE #: <br />DATE: L (V2— <br />ZASSIGNED <br />ASSIGNED TO: �ag� F -�— <br />EMPLOYEE <br />DATk: ( Zi <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P F E:.)-3 p�` <br />Fee Amount: <br />Amount Paid <br />w3?S a-<::) <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />13'0 <br />Received By: <br />FHD 48-02-025 SR FORM (Golden Rod) <br />FRF_VISEO 11/47/2003 <br />