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SAN JOAQUIN COIINTY ENVIRONMENTAI, FTUAl.:-1.1 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 0,0 7o35/-y <br /> OWNS //0111112MMR CHECK if 13ILLING ADDRES31:3 <br /> FACILITY NAME �` ..--Tlk' O <br /> SITE ADDRESS �� <br /> /v �I zl <br /> 2_G d Elrod Numbel Di—tion ere t Nema <br /> HOME Or MAILING ADDRESS (It Different from Site Addre/e <br /> STATE LP <br /> CITY 60 IJ c o Q 04. 9 KIT-1 <br /> PHON50 ExT• APN LAND USE APPLICATION S <br /> (q 15'T 011 _?_ .- ; -I— <br /> PHONE1102 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACrfOR /SERVICE REQUESTOR <br /> REQUESTOR CNECK if BIDING ADDRIES31:1 <br /> BUSINt:as NAME PHONE N Err' <br /> HOME or MAIL1No ADDRESS FAX <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or p%jcct specific T NVlltf)N?vfliNl'A1..hil,,Ai_1'lI DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the wnrk in he periorrnc(j will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance C'vdes,Standards, IXAL,laws. <br /> APPLICANT'S SIGNATURE: _ I)ATT: t�� I � <br /> PRorEkTl'I BUSINESN OWNFRM' 0I11'1'>R/MANAGEM 13Orrilli Alrl'wPR1'(,F,I)AGENT❑ <br /> i APPLIC'AMT is 110,the B LL1AY1 PARTY,proof of aufhorizpoon!o sign is required Title <br /> AtJTHORIZ-ATION TO REL A LINFORMATION: When applicable, f, the owner or operator of the property located at the <br /> above site address, bereby authorize the release of imy and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY I;NVIRONIVIVNI'AI.}II".n1.Tll►)i:P,1kIMI!N'f as soon as it is available and at the name time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: _ Y�FNT <br /> Co <br /> MMENTS: Qooky Pot PA 611-1 Gansu 41p%f U-, �FNFo <br /> '.W44 <br /> !�% <br /> • <br /> 0. <br /> �l <br /> ACCEPTED BY: Bt, Cs C01VIL-0 — EMPLOYEE#: Q(0.;P_ DATE V19)�� <br /> A95113NED TO: Zen es Zlo EMPLOYEE 1t: �,wa DATE' i91191M <br /> Date Servloe Completed (If already completed); SERVICE COOE: e)61 P I E: 4103 <br /> Fee Amount: 2(0() Amount Pald U,Mp� —� Payment Dace - <br /> Payment Type V I v, Invoice# CC1e� 7 9'67 q'q eceived By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Au5-, 18. 2014 3: 03PM No, 1088 <br />