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SAN JOAQUIN COUNTY ENVIRONMENTAL IIFAL.TII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID Y SERVIC <br /> E <br /> REQUEST 0 <br /> �uZ �T `f <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FActrY NAME <br /> SITE ADDRESS ZZ I S <br /> Street NumM Dlrtttbn Sbeel Nam , ZI �° <br /> HOME or MAILING ADDRESS (If Difemnt from Site Address) 1\t6✓` �xr)',t.y,/v'vNvo <br /> Su Say"Nu r <br /> CITY L-O''11 ST 1V <br /> P"a It EST• APN 6 LAND USE APPLICATKm 0 <br /> 120 r✓t Z`5 L <br /> PWmE 12 Ell BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHEeK R BiLLIMG ADDRESS <br /> BUSINESS NAME PNDRE <br /> 19 S <br /> HOME or MAILING ADDRESS FAX 9 <br /> ( 1 <br /> Cftt STATE Z.rP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same. <br /> acl0}owFLdge that all Site an for project Specific ENVIRONM1IFNTAL ILEALTII Dt:PARTMLNr hourly charges associated with this projeci <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQviN <br /> Cowry Ordinance Codes,Standards,STATE and FFEDFZtAI. laws. , <br /> APPLICANT'S SIGNATURE: ' ^W_ DATE: 1:L <br /> PROPERTY/Bi'sLNm OwVERIp OP UT'ORIMA\AGER ❑ 0TuERAI1TuORIZEDAC,L\7❑ <br /> Jf.1PPL1cAAT is not the IJr1lJ,CG PARTY.proof ojouthorizotion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, ilk, owner or operator of the property Iocawd at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data andlor environmuntallsite assessment <br /> information to the SAN JOAQurN COUNTY FTIvtRONwNTAL HEALTH DEPARTNtENT as Soon as it is available and,at the Same time it is <br /> provided to me or my representative. A y <br /> TYPE OF SERVICE REQUESTED: `i <br /> cows LITS: s AN 64? <br /> NF N'/04 o tiMR <br /> of W oe h► P IENT <br /> ACCEPTED BY: EMPLOYEE a'1: 1 Q DATE: I ZZ <br /> ASSIGNED TO: EMPLOYEE C; V DATE:' <br /> Date Service Completed (Ii alreadycompteted): SERVICE CODE: PIE: <br /> FecAmoun ' v Amount Pa -10ij �� Payment Date <br /> Payment Typo ` Invoice N Check 9 13 0OS52 eeelved By: <br /> REHDEV 48-02-025 � � SR FORM(GD4den Rod; <br /> REVISED 11/1 78003 <br />