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SAN JOAQUIN cot Inv ENVIRONMENTAL IIF,ALTII DEPART MENU <br />SERVICE REQI JEST Fg 05 1-4 3 "loiv <br />Typo of Business or Property <br />t\it t'i) 'Grtee 4-4( C 1 "Q <br />FACILITY ID II n i\ev omeecvt v ' <br />SERVICE REQUEST # , <br />r:DZON054-4 <br />OWNER / OPERATOR <br />CHECK If <br />-s '1H 1 /) AlA efli flu CeiA Hotisli A - c-i 161( it 46/1414 NILLING ADORES A.} <br />FAcarry NAME 0 S1 A A 0 ' " qi 114 11 ,4 I <br />SITE ADDRESS <br />) 18 <br />Street Number Di recoon <br />cti,itv\i-) II 01 cl <br />Street Name <br />ylouttitti fl i (-)1( <br />City --kl)Ccitik--- <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />NONE # Ex <br />1 <br />APN # LAND USE APPLICATION H <br />NONE #2 EXT BOS DISTRICT <br />( ) <br />LOCATION CODE <br />CONTRACTOR / SERVICE RUN JESTOR <br />REQUESTOR <br />CHECK If PILLING ADDRESS <br />BUSINESS NAME <br />( ) <br />PHONE # <br />HOME or MAILING ADDRESS FAx # <br />( 1 <br />Orr STATE ZIP <br />PILLING ACKNOWLEDGEMENT I the undersigned property or business owner, operator or authored agent of same, <br />acknowledge that all site and/or project specific ENviRoNMENTAI, HEALTH DEPARTMEN1 hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAlE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: C DATE: ()3 I 22-1 2-C),--3 <br />PROPERTY / BUSINESS OWNER ET OPERATOR / MANAGER 0 OTHER AI THORIZED AGENT 0 <br />1.1. A Pitic'.1v7' is not the fill LING PARTI proof Of authorization to sign is required Title <br />AUTHORIZATION 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 and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: reD4 4‘rat fel f(a-rt, 1-tecle--- <br />COMMENTS: R EC C E! vED <br />JP,AYNicE.NuT <br />MAR DE2: R T <br />EN <br />2023 <br />..—AQ H ui N SANE <br />NM ENVIRO Ta <br />NTy <br />A <br /> <br />to- <br />ACCEPTED BY: cvarive6 EMPLOYEE #: DATE: :3 -2-1 - .23 <br />ASSIGNED TO: Ca‘ve v Li..e4a EMPLOYEE #: DATE: _ ...2a, 72,3 <br />Date Service Completed (if already completed): SERVICE CODE: S -).....3 P I E: f&c)( <br />Fee Amount:4 <br />. <br />s,0D Amount Paid ti.` cks.,DD Payment Date 3/423 <br />Payment TypeCRJ;_t Invoice * Check # 13--7,2,47 j,-/-1- Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)