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SAN 1OA(JIUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typool siness or Property FACIUTYID# SERVICE REQUESTS <br /> OWNERI OPERATOR <br /> l 1' CNfCi(N811.LIHD ADDRESS <br /> FA41utYNAME <br /> SITE ADDRESS �r] t er �I A(2-011v\ P.l��'GJ' f (Al. 9,S�?D` <br /> HOME or Miiiwa ADDREEsss (if Different from Site Address) n 2� I "co I` /t l_�` v` <br /> -N Mae L�i - ^� <br /> CIN LO f O " \ - _ - - STATE IMP <br /> PHD #1l'' �IT. AFN9 LAND Use APAI.luTION <br /> I # <br /> PHONEP2 EaT• BOS DISTRICT lOGATIDN COBE <br /> f 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REDUESTOR <br /> ` CHEDR H(},�,�Iljrt�ODAE49� <br /> BusiNEss NAME <br /> HOME er AIL�/SOD Col /1 -���— FAX p <br /> �j� t ) <br /> CITYCJS -- / Q TATE ZlW 'J <br /> HILLIliGACKNO_MUMIGEMENT: 1, the undersigned property or business owner, operator or authorised agent of same, <br /> acknowledge that all sits and+or project Specilic ENVIRONMENTAL ITP=4,L111 DtTAR'rmEKr hourly cbarges associated with this project <br /> or activity will be billed to me or my business as identified on :s orm. <br /> I also certify that I have prepared this application and a t th ork to be performed mgll be done in accordance wi alt SAN JOAgUIN <br /> CUDNi'y Ordinance Codes,Standards,$IATE QED -law <br /> �/ q-) <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PRQAERTY/BIMNT;SS OWWUR{M( OPERATOR!A'IANAGERO OTHER AtTTRORILED AGENT <br /> IjArruCEN'Tis not the RILLL T:Essar,proof ejauthorization to sign ii'requked T';rta <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of theproperty located at the <br /> above site address, hereby authorise the release of any and all results, geotechnical data and/ur enviruafn nial;sitc assessment <br /> information to the SAN JOAQuiN C'ouxi-V ENv1RONMENT AL M-ALTii DEPAttT TENT as soon as it is available and at the same time it is <br /> provided to me or my representative_ <br /> TYPE of SERVICE REQUESTED: <br /> C(vM€HTS: 0 VCAf- �v�v t, C) ire 5-�u.µIt, �� C <br /> Sq <br /> ?0 <br /> HE `TNOQq ETA�O <br /> ACCEPTED BY: rr✓C G S Ga EMPLOYEE#: <br /> As51GNEDTo: .7L� atm- EMPLOYEE#: DATE: 1—/4 - 10 <br /> Date Service Completed (if already completed): SERVIDECODE: rOG P J E: <br /> Fee Amount: �Sd.�� Amount Paid k1D Payment Oato <br /> Payment Type Invoice# chew # /'S— Received By <br /> e-ID 48-012-025 if- <br /> SR FORM(Golden Rod) <br /> REVISED 11/17.2003 <br />