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SAN JOAQUIN COUNTY ENVIRONMENTAL IJEAIL'rii DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 644 <br /> M 0 b, Tr- 0 -3\L-1 <br /> OWNER/OPERATOR (� <br /> tv- a, r(� CHECK It`BILLING ADDRESS <br /> t l� <br /> ^"FACILITY NAME <br /> SITE ADDRESSaq tj� r" S+'-o t:.I<+0' q5�—V6 <br /> 4# Jot 1 �'�0 <br /> Street Number Dlrection Street Nam Cit ZI Codc <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Qa t K)Oim S C Street Number Street Namo <br /> CITY S+a c k0 STATE C A Zip 9 5 �� <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> 0091 3� - 72.0 <br /> PHONE#T ExT. B05 DISTRICT LOCATION CODE <br /> i 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR P.Q CHECK If BILLING ADDRESS❑ <br /> � e.lr <br /> BUSINESS NAMEr PHO91- �� , 7 D Exr- <br /> C A Co1-Ff?r-f(.t <br /> HOME or MAILING ADDRESS FAX# <br /> CITY [� /�-V C <— t STATE zip L S'a C <br /> BILLING ACKNOWLEDGEMENT: I, the undersignt:d property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRQNMLNTAL HEAL1'I-i D!iPARTME-N'C hourly charges associated with this project <br /> or activity will be tilled to me v, my bu3inesa a;.identified on this Form. , _ _•tr <br /> 1 also certify that l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codec,Standards, STATE and FEDERAL laws. <br /> ATPLiCANT'S SIGNATURE: d i ( -1 fj DAi 2 f <br /> PROPERTY/13USINFSS0wvrR❑ OPERATOR/MANAGER ❑ OTIIERAUTHORIZEDAGENT❑� <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results. geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONNtENTAL HEALTH DEPARTMENT 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: C7 (,( NrifiT! o i i Q <br /> 60 tw <br /> COMMENTS: <br /> civ <br /> JAN 12 20,21 <br /> _ AQLr1N CDu <br /> ACCEPTED BY: & '�'r1,ne EMPLOYEE M DATE. 0CjiADt.'� <br /> ASSIGNED TO: lv� ' 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �.Q, P 1 E: x <br /> Fee Amount: <1 �5 Amount Paid dil <br /> f J Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />