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f SAN JOAQUIN COUN'CY ENVIIIONMENTAL HE.Auni llEi'AWFIVIE.NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# C SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILUNO ADDRESS❑ <br /> FACtLay NAME <br /> 1 Oen <br /> SITE ADDRESS ,/� Sk, 1"onke(c\ _(�c)�' /W <br /> Street Number DlrocUon Street Name i Zip Code <br /> HOME Or MAILING`^^ IlADDRESS (if Different from Site Address) <br /> lv• \ StreetNumber strett Name <br /> CI STATE ZIP <br /> C C C1 <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> i dor c�1-e <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> V ( I <br /> CITY /, STATE Zip C Cj <br /> ]BILLING ACKNOWLF.I)GFMFNT: I, the undersigned property or business owner, operator or authorized went of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL IhsAuni DEPAR'I'MlN'I'hourly charges associated with this project <br /> or activity will be billed to me or my business as idenlifled on this form. <br /> I also certify that i have prepared this application and that the work to be perforn)ed will be done in accordance with all SAN JOAQUIN <br /> CotrNW Ordinance Codes,Standards,STATti and KEDFRAL laws. <br /> APPLICANT'S SIGNATURE: DA'I'E: <br /> PROPERTY/BUSiNMOWNFR❑ OPERATOR/MANAGER ❑ OTIIFRAui,itoRizF:i)A(:I:N-,J!� <br /> IfAP1'1JCA,VT is/lot the BILLING PART}'.proof of authorization to sign is required i rt <br /> AUTHORiZATION TO RELEASE, INFORMATION: When applicable, I, the owner or operator of die 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 /> illfonnaliOn to the SAN JOAQUIN COUNTY I.NVIRONMEN'1'AI.I IFALI'll I)t:PAl11MI:9I' as soon as it is available and at the sante time it is <br /> provided to the or my representative. <br /> TYPE OF SERVICE REQUESTED: C 0 M S LI L 1-h Tl 0 f,I EMT <br /> COMMENTS: RFC+ ` <br /> MAY 2 0 2021 <br /> SA ENVO RON'MENTAL Y <br /> HEALTH DEPART MENS <br /> ACCEPTED BY: I N(F 14 <br /> EMPLOYEE M g 3 G DATE. 6);01.7 <br /> ASSIGNED TO: �4 I KI&-14 EMPLOYEE#: DATE: Jt/;Z 0/a 1 <br /> Dato Servico Completed (if already completed): SERVX:ECODE: 041/ PIE: q I 0 3 <br /> Foe Amount: ffi 151 Amount Paid 8 16-2- Paymont Dato 6/,L70/.21 <br /> Payment Typo Vt 4,A_� I Invoice# t?� I�# 2 z Received By: ) <br /> EHD 48-02-025 �� l�1f SR FORM(Golden Rad) <br /> REVISED 11117/2003 <br />