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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVIC E REQUEST <br />FACILRY ID # SERVICE REQUEST i>t <br />Type of Business or Property j ,�'1 , ] 2j1 l l <br />iZ�ss lDt1t�T,�K.. a�� Dt9 3 <br />OWNER / OPERATOR <br />FAcam NAME <br />HDPE or <br />Crnr <br />DitTamnt from Site Address) <br />Err. <br />APN <br />O tz <br />CONTRACTOR /SERVICE <br />IZ <br />Stry�t Nsm�— <br />STATE zip <br />LAND USE APPLICATION ft <br />BOS DISTRICT <br />IUESTOR <br />CHECKif <br />�.iZ <br />LOCATION DO0�I9�H /N C <br />NEA EPgR rAL TY <br />MENT <br />HoMEor ADDRE��Ly� (Ax# ) <br />STATE LP / <br />BILLM; ACK�iONNIM)GEMENT: L the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site andlor project specific ENVIRON.MwTAL HEALTH DEPARTMEti7 hourly charges associated with this project <br />or activity veil be billed to me or mWappo <br />on this form_ <br />I also certify that 1 have preparedhe work to be performed will be done in accordance with all SAN JOAQUINCou,%7y Ordinance Codes, Sta laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PRorrm i Brsrmss ow.Eu© Or SVO MACER ❑ OTIaER AL7HoRrzFv AGENT it LSe 17� <br />If44PP11GL%Tis n r the Bfuty PAR". proof of authorization to sign is requirKd Title <br />�IrMORIZATION 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 andlor environmentaUsite assessment <br />information to the SAN JOAQUua COUNTY ENv1RON ALN rAL HEALTH DEPAR'T:vtEt4T as soon as it is available and at the same time it is <br />provided to me or my representative. <br />Trr! oFSERviceREuuEsr®; er, [^IlS}c; I?C� J� Se. 1 t) r <br />t.oroEnrs: Sz�d //�S G�/l�•J ?'D GD S tS P % D <br />��6� �•� Off%. �itNierA 4fr �nf Ys% <br />GCi, lq i, ,S Ie.sp3:lr1s It C�,,r exp, <br />eta/,. EOD imge(Yor 1-J Vt�'� (7r1Sf <br />0(J- e,�3T �17 J �'Gl1t'E�./JlF R0 jl'IS, <br />n i p I, Gf <br />rPot; t✓2c� - �i <br />ACCEPTED BY: �� / EMPLOYEE#: <br />NEW <br />AsmGNmto:DA L DAA ils/, <br />EMPLOYEE #: <br />DATE: <br />n <br />Date Service CotnploW (a already complsW): <br />SER�CODE: <br />Fee Amount: L' �, <br />�I Amount Pai C <br />Payment Type ���� dDD Payment Date <br />�KL Invoice # Check # <br />EHD 48-02-025 <br />REVISED I InTr&M <br />Received By; <br />SR FORM (Go{den Rte) <br />