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APPLICANT'S SIGNATURE:
<br />PROPERTY / BUSINESS OWNE
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property FACILITY ID # SERVICE REQUEST #
<br />S ICOGWI:(4°
<br />OWNER/ OPERATOR
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<br />CHECK if
<br />/ /7( ,e7-1/- Li rd
<br />BILLING ADDRESS
<br />FACILITY NAME
<br />Street Ndnber
<br />SITE ADDRESS
<br />Direction Street Name _f70,/,--,,A) City q_c--,,l)f__ ip ode
<br />HOME Or MAILING ADDRESS (If Different from Site Address)
<br />Street Number Street Name
<br />Crry STATE ZIP
<br />PHONE #1 EXT.
<br />( ) q --' 6- /67
<br />APN #
<br />0 K D 9
<br />LAND USE APPLICATION if
<br />PHONE #2 EXT.
<br />( )
<br />BOS DISTRICT L i LOCATION CODE
<br />0 r:' 1 ' i
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR i
<br />-A //, / /A/2/-1 /47//6;1--
<br />,,
<br />1
<br />CHECK if BILLING ADDRESS CS3
<br />BUSINESS NAME PHONE # z,
<br />r2'7/c 60 —
<br />EXT.
<br />HOME or MAILING ADDRESS _ FAX #
<br />CITY -, .7, C STATE ZIP ,a(---7
<br />— / e
<br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,
<br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTFI DEPARTMENT 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 applicatio and that the work to be 1:1 r formed will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standards, STATV'lcl FEDERAL laws.
<br />-
<br />PERATOR / MANAGER El OTHER AUTHORIZED AGENT 0
<br />If APPLICANT 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 ENVIRONMENTAL 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: Ve( , cy ttic.f 41 re is 110 TC.3 n' r., /40//,, JO li'neS CD-r pits
<br />COMMENTS:
<br />f/-11.f 17 ,<', -- )(15— )/))//_r /13A N _.- liti.cite
<br />il ir f C/ 1///vz,_ i N.c, ferTvills zio C..le P,,rosed i tvJc p cys i s MI yol . yy, , 0
<br />-1,Aes V e i , cy n 0 ,Je II,- CO'7G/ pCiet. ior sp c c,Ict I verrvi' t Vf Y 1 / Li e 11 OA. /cif) ii 1 iH eC4 OA D ,
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<br />Sg 0 0 1-1 ,)100 I's de), I roy rof or nut *bele . SAN Jo
<br />Aolimr
<br />ACCEPTED BY: ,..--72- Z„...,/..._, EMPLOYEE #: DATE:
<br />ASSIGNED TO: A EMPLOYEE #: DATE:
<br />rTZ`i"
<br />Date Service Completed (if already completed): SERVICE CODE: (., i
<br />Payment Date
<br />Received
<br />Sip/21
<br />P1 E: i-poc)
<br />By: tail-7(
<br />Fee Amount: *VS" ()_ Amount Paid lp (9--1 ----
<br />1
<br />Payment Type de., Invoice if Check # 1,1011_1(p
<br />DATE: -/ -
<br />921
<br />END 48-02-025
<br />REVISED 11/17/2003
<br />SR FORM (Golden Rod)
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