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SAN JOAQUIN COUNTY E NwRONMENTAL HEALTH DEPARTMENT <br /> i <br /> SERVICE REQUEST I <br /> of Business or Property FACILITY ID# SERVICE REQUEST# ! <br /> OWNeR/OPGRATOR Cmc If( wtao Aaor:ess❑ <br /> SITE � 7►v�►$- Q.CII (2i pUYt q 3�f s� <br /> ( „ Mix <br /> HOME Or MAILING AOMSS (N Different from Site Address) <br /> e K <br /> CITY STATE zip j <br /> Pllost=at APN# LAND Use APaueATM <br /> gpg LOCATION Coodi <br /> tete k2 <br /> 1 ) <br /> CONTRACTOR SERVICE REQUEST®R <br /> REQUESTO C► Gc if Bil UNG AA ® ❑ <br /> euswiies NAM�.-�- a9a —l IAJA <br /> Home or ADDRESS RAXti <br /> - 538 <br /> t Zvi►3'��" '�"t'3 <br /> CITYi. 3rA Zip SSD <br /> t 1,61Ng ACKNOWLRdGEINENT: 1, the undersigned property or business owner, operator or autherized agent ck same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HIIAi.rtl DEPARTmi:NT hourly charges associated with this(`project <br /> or activity will be billed to me or my business as identifled on this form. <br /> I also certify that I have prepared this applicetion and that the work to be performed will be done in accordance with all SAN JaAQULN <br /> co tmv C?rdinance Cartes,Sruedardl,STATE sed FrDERAL laws. <br /> APPLICANT'S SIGNATURE: r.- "r� DAM — <br /> Pkr/rVkTV 1 aaswru 0wmm l3 OP%PATar/Ma G91t® D•ntrtR AtmtoRerAo AGIWr&? <br /> lPArrar040r Lr,wr the&&L(OCf%P.rxly IRPanrharhwtfon tos�n is regx1red Terra <br /> !i roc <br /> 6L!TH()BIZATIQN Til;LMIS LNEQ&MA QN:When applicable,[,the owner or operator of the property loom I at the <br /> above slat address, hereby authorize the release of-my And oil results,Seotechnical data and/or environmentallsite asstissment <br /> information to the SAN JOAQUIN COUNTY F.NVIRONMRN'rAL HuAt.114 DRPARTMI;NT as soon as it is available and ut the same tune It is <br /> provided to me or my Wresontative. <br /> TYPE OF SERVICE REDUESTEO: <br /> Co mmaNrs: <br /> 1 <br /> I <br /> ACCEPTED BY: Ba+Pr.exvee#: DATE: � <br /> DATm <br /> A9alONLD TO: EMPLOYeE M. <br /> Date Service Completed (if olmoy completed): Ste CME: p 1 E <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Recolved Sy: <br /> eatD�e-oa.oas SR FORM( Rod) <br /> REViSSD 1111712003 <br /> S0/Z8 39vd A90'XNNFtdl £bST99E60Z 911:T7 888Z/E1/98 <br />