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000bo <br /> f(2- <br /> DIa0 b2 �3 <br /> �� .it)\t ll IN <br /> ( t)i'�'Tl' 1.�� IIZON11P:�T:�1 III 11.1 II 'ARTi� <br /> _ <br /> St Iz l('E RLQULS" <br /> SERVICE REQUEST* <br /> —�11- F�ILITYID#� g� ����g-7404- <br /> Type of Business or Property II U V�t <br /> L1 c cJ 1— CHECK 1f BILLING ADDRESS <br /> OWNER I OPERATORrq <br /> n <br /> FACRRY NAME <br /> I-AM EZ[o <br /> 3 Cod* <br /> � <br /> s"f C <br /> f"* <br /> SITE ADDRESS � � �� c' <br /> 1 Street Nime <br /> Street Number DIIaUmn <br /> HOME Or MAILING ADDRESS (If Different Horn Site Address) Street Name <br /> Street Number STATE ZIP <br /> CITY <br /> LAND USE APPLICATION# <br /> PHONE#1 E.i. APN# <br /> (SIU ) "Uy—q BOS DISTRICT LOCATION CODE <br /> PHONE#2 E.T. <br /> CONTRACT01Z/SER VICE IZEQUEST0R <br /> CHECK if BILLING ADDRESS <br /> REQUESTOR <br /> BUSINESS NAME <br /> I � FAxq <br /> �,/ <br /> HOME or MAILING ADDRESS �jt C � � ��.!\ 1 J1-- ( ) <br /> —1 J STATE CZIP <br /> CITY T <br /> Pk S <br /> siness owner. operator <br /> BILLING ACIiN VLF.DGE HENT: I, the undersigned property or bus authorized agent associated with this project or <br /> of same. <br /> acknowledge that all site andor project specific ENVFRONNIENIAL IIFAI Tit DF.PARIAIENT hourly charges <br /> activity%Fill be billed to me or nn•business as identified on this form. <br /> I also certify that I ha%e prepared this application and that the work to be performed will be done in accordance�ti'ith all SAN Jo,\Cit IN <br /> COUNTY OrdNtmtce Codes,Stmulurds,STATE and FC171:IL\I laws. <br /> D.\Te: <br /> APPLIC:\x T•S SIGNATURE: <br /> ! PROPfRTI til'Is`1:ti50«'NER0 <br /> 0PI"HAT0R/MANAGER OTneR At I'NORlzFD:AGK.-,I ❑ <br /> 11.dPPL1CdNT is not theB1L11A'GAIRIY,proof of arrthOrizatiotr to sil!n is required Title <br /> tJTIIORILATION TO RELEASE INFORNIATION: when applicable, I, the owner of operator of the property located at ill,: <br /> above site address, hereby authorize the release of any and all results, geotechnical data and or environmental/�y!by, , <br /> infornTation to the SAN JOAQUIN COUNTY ENVIRONNII°NIAI.IIFAIA11 DFI.,!'\F `;r:r, soon as it is available and at th e[11. <br /> provided to me or m} representative. <br /> TYPE OF SERVICE REOUESTED: Q C <br /> COMMENTS: SAN 2023 <br /> NEq TH EPg1—NZJOAQLIIN 4 Ty <br /> rM r <br /> ACCEPTED BY. EMPLOYEE#: DATE: <br /> �.e� <br /> ASSIGNED TU' EMPLOYEE#: DATE: <br /> �� Y�(f�, — .__ -- <br /> DServictr' <br /> l): CODf.: <br /> ato PIE: b�'Z <br /> ` \^ 2- —_ Amount Paid �7jRVICE <br /> Payment Date `1 ��— 23 — <br /> Feo Am•, " . V <br /> Invoice# Chock# 1�r✓ / Receivod By: <br /> Payment IiI- cc 7 <br /> -- - I tiI <br /> t_H' SR F0RM(Golden Rod) <br />