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SAN JOAQUIN COUNTY ENVIRONMENTAL 11r.ALTH DFPART;NIFNT <br /> SERVICE. REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fp Da o004 � SROoicoo99 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRE99O <br /> FActm NAME t <br /> SITE ADDRESS �j11Q.- 'I.�JC-Gv�(/Yl <br /> /. SINel Nvmbr Imcra ImrIN c 1 <br /> HO. Or MAILING ADDRESS (if Different from Site Address) e <br /> 9vNl Numbr _J�` sloe Nam <br /> ,CII/TTY+`,E/��ry STATE/f N ZP �C <br /> Pr <br /> )NR5�N58 En APNa LANG USE APPUCATONa J <br /> (�(J� <br /> P "p En. BOS DISTRICT LOCATION CODE <br /> E 1 !`— d�=J�0 <br /> + CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR n CHECK if 131LUNO AOORESS❑ <br /> ICA <br /> • V` O fMONE# En. <br /> BUSINESS NAME <br /> HoME0r�1 LI GA RE Fu# <br /> vri mialld ( ) <br /> CrY i STATE ZP <br /> BILLING ACKNOIVLEDGENIEINT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all Site and/Or project Specific ENVIRONMENTAL HEALTH DLPARTMLNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Smndard-, Ii <br /> F and FI°I laws. <br /> r ( <br /> APPLICANT'SSIGNATURE• DATE: /1/222 <br /> PROPLRT)/DI SINFSN ONNERO OPLR\TOR/)I\Nr,LR❑ OT HER ALTOORIZED AGENT <br /> /J.IPPL/ol.x t is no/the H2uv(;P,IRn.proaJojaulGorizaTion Fa sign/s squired lute <br /> j AUTHORIZATION TO RELEASE INFORMATION:When applicable,1.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 andfor environmental/site assessment <br /> information to the SAN JOAQUIN COIDJTY ENVIRONMLNfAI.HEAI.TII DEPARINIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> • TYPE OFSERVICE REQUESTED: <br /> COMMENTS: I <br /> C� o� UcT9 h <br /> ACCEPTED BY: _. EMPLOYEE#: 8 DATE: 11/29 2 <br /> ASSIGNED TO: �r EMPLOYEE X: 8 ^/"O r� DATE: /� -,7 Z , <br /> Date Service Completed (if already completed): SERMCECODE: t I PIE: <br /> Fee Amount: f 6 Amount Paid Payment Date 2 Z <br /> Payment Type Invoice# Checc.,k{f# / nReceived By: <br /> EHD 48-02-025 l..Oft\ —I I 17 3 ��C` Q cam., F (Golden Rod) <br /> REVISED it/172003 <br /> Xr- <br /> r►.-.rlTil:�r�TeTcslrt"V_"C5'?Fc:.�l'-�W V:@'i'v,Htl.T7.'�.a?x�r/y/,'/' ,.L.9-�i-^!:(v:Nf.T::'Rr, <br /> p�OI(a3 Ls� <br />