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SAN JOAQUIN CMN'I'Y' ENN'IRONMEN'1-A1. HEArrii DEPARTi11EN'1' <br /> Type of l3 <br /> usiness <br /> or Property SERVICE REQUEST <br /> � <br /> C' <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNERS ERATo C�'*(I .l( 4� TU(it oflil YAV 1 F Ls 00, /17 <br /> milli <br /> FA <br /> CILITY NAME Mil 14 Mo,,10 AA l A M CHECK If BILLING ADDRESS C� <br /> �—.ITTLF_ 1_ EioIZL <br /> SITE ADDRESS <br /> 30 �-S <br /> DT <br /> I (IS�jo <br /> HOME or MAI ber Direction Street Name Ci Zi Code <br /> UNG/ADDRESS (If Different from Site Address) <br /> CITY Street Number Street Name <br /> STATE ZIP <br /> P4+eNE#1( —C- <br /> -J <br /> ^- 1 i E�— <br /> ._ T i Al LAND USE APPLICATION#z� I �—r..{ �,� f cam-�t <br /> P 2 P(I Exr <br /> BOS DISTRICT LOCATION CODE <br /> + <br /> ( 10 ) .— _ <br /> 5�3y7k 11 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> h�lJ H A M(;\A �� AAI—A 0CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME or MAILING ADDRESS FAX# <br /> Z>01 S Cc,c1�-�r"n I f��/c=(lel ( ) <br /> CITY t C` ` STATE ( A ZIP G Z U <br /> BILLING ACKNOWLEDGE.NTENT: I_ the undersigned property or business il ner, operator or authorized agent of same. <br /> acknowledge that all site and)or project specific ENVIRO NM VIAL HEALTH DF..PARI;1tLNI 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 JO.%Q( I\ <br /> i I Y Ordinance Codes,Standards. S rA rLan FLlaws. <br /> APPLICANT'S SIGNATURE: miDA re: t�C���-� �� y <br /> PROPERT 1isiNESsONNER OPLRAIOR/.%L%NAGER ❑ OIIIER:1kl IIIORIZt.DA(;tSI ❑ 1 �� �//� ,���✓ <br /> /I'iPPLICAA l is not the BILL/AG P.IR7).proof of authorization to sign is required TiNe [At L�.lxt <br /> ALITHORIZATION '1'0 RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the JJ <br /> above site address, hereby authorize the release of anv and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOA(,It;IN Cul:I Y ENVIRO)N%lLN I AL I ILAL 11-1 DLPAR I MLN t as soon as it is available and at th0i time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ®1. <br /> COMMENTS: O 0 <br /> Sq^,✓oq 20 <br /> 20 <br /> N Fiy�iR�VAN�� <br /> E9(py C pq�M 4 7)_ <br /> FNT <br /> ACCEPTED BY: k EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> n PIE: �� L <br /> Fee Amount: �'2 Amount Pai O PaymeEA <br /> nt Date <br /> Payment Type Invoice# Check!��- d Recei�red By: <br /> Ell 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />