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SAN JOAQUIN COUNTY ENVIRONMF.NTALHEALTH DC-PAIZTMENT <br /> i <br /> SERVICE PE QUEST <br /> FACILITY ID# SERVICE REQUEST <br /> of Business or Property n <br /> I <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> fFAGILrry NAME f © G.7�j ©�,�r� <br /> SITE ADDRESS ` � (. �(7 N f Zia codh <br /> JJ Vnul amu CI <br /> Street NuAlbor Me tion <br /> HOME or MAILING ADDRESS (if Different from Sita Address) <br /> SfreotNwttber S otNa a <br /> STATE Zap <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# ! <br /> PHONE#1 <br /> PHONE 92 <br /> Ex> BOS DISTRICT <br /> LOcAnON C0o91 <br /> ( 1 <br /> CONTRACTOR J SERVICE REQUESTOR <br /> REQUESTO CHECK if <br /> _BILLING AOCRES f <br /> PHONE# Exi <br /> BUSINESS NAME�� p ?b't I z-G `( ZAJ' <br /> FA:.# I , <br /> HoraE or MAILING ADDRESSCAP <br /> ? <br /> Gt!• !f CGt� STA ZIP cis—OLI/0 <br /> CITY �•,�, <br /> BILLING ACKNOWLEDGENIEN'I': I, the undersigned property or busirtiess owner, operator or authoriLatl agent e1"same• <br /> acknowledge that all site and/or project specific ENVIRONMGNTAI,HEAL'I'll D PARTMEN'T hourly charges associated with this!project <br /> or activity will be billed to me or my business as identified Ott this form. <br /> ed <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN lclAtlulN <br /> i <br /> CtIUN1'Y Ordinance(�0deN,Srurrdurrla,S•TA'I%and 1713,DGttAL laws, <br /> llA rl?: <br /> APPLICANT'S SlCNA'I'UItE: <br /> P1torturr'Y I lJosINF ss owmm® ()PRrt TOIL 1 h9ArrnCt R ® ID'r•Iiert AU r trORV.Rn AGHxt'r' ?'Iris <br /> I/,$t'NLIC�tN1'ix nut the Rft.t 7V.pruof of rutrlaarizUtiar In si1,m is regafred <br /> All•rHORIZATION TO RELEASE;INFORMATION:When applicable., I,the owner or operator of the property locAteli at the <br /> above site address, hereby authorize the release of-any and till results, gcotechnicat data and/or environmentl►Ilsitc assetssmait <br /> inlbrmation Co thtz SAN J0AquIN COUNTY ENVIRONMh'N'rm,HLA1,1m D14,PARTME" 'r as soon as it is available and at the same time it is <br /> provided to me or my rcpresontative. <br /> TYPE DF SERVICiB REQUESTED: <br /> COMMENTS: � <br /> I <br /> i <br /> EMPLOYEE 0: DATE: <br /> ACCEPTED BY: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> SERVICE Coot: P I E: <br /> Date Service Completed (if aireacty completed): <br /> Fee Amount. Amount paid Payment t7ate <br /> Payment Type Invoice# Check# Received By: <br /> BHO�8 02.025 SR FORM(GOic�er.Rod) <br /> REVISED 11/1712403 <br /> SO/Z0 33Cd A90-10NANVI COST99£60Z 9b:TT 800Z/6T/90 <br />