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r I SAN JOAQCOUN'I'Y ENVIRONMENTAL HEADEPAR IVIl T <br /> SERVICE REQUEST <br /> Type of Business or FACILITY ID# SERVICE REQUEST# <br /> rope <br /> 20nLl <br /> OWNER/ PERAT R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDIRES <br /> fSlreel Number Direction <br /> H or MAIL G ADDR-SS (II 1 r nt Irotn Site Address) <br /> Slreel Number <br /> CITY STA Zip Z OS <br /> PHONE 111 E.T. APN0 �(p —d�D—b�/j/3/ D USE APPLICATION# <br /> t�jl.'gs7—ZS`55 /� � L 030^0l OZ C <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOT1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ile , PHONE � �C•`�I)XT• <br /> .� HOME or MAILING ADDRESS FAX 0 � � <br /> ( SNJ -la m <br /> CITY STAT ZIP 17 <br /> 2 11 'l <br /> BIIAANG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMEN•I'AL IIEAU11i DF-PARTMEN•r hourly charges associated with this project or <br /> activity will be billed to ole or my business as idenlifi n this form. <br /> I also certify That I have prepared This application nd Ih the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandarrlw,S I ul RD.W_laws. <br /> At'1'LICAN'I"S SIGNATURE: DATE: 7 <br /> PROPERTY/BUSINESSOWNEII❑ OPEIIAToI/MANAGER OTimut AD7GOitIZ).D AGENTS <br /> /f APPLICANT is No/rile BILLING PARTY.proof of authorization to sign is required Title <br /> ALY1110RIZA'110N TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located of 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 COUN'T'Y ENVIRONMENTAL.IIEAurii 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: �( ENT <br /> COMMENTS: <br /> JUN 17 2003 <br /> SAN JOAOIJIN COUNTY <br /> Pt161.1C 1IEALTH SERVICES <br /> ENVIRONMI ITAI HFAITHDIVISION <br /> APPROVED GY. EMPLOYEE 7l: DATE: (o 11-7105 <br /> ASSIGNEE)TO: / EMPLOYEE#: DATE: 6/17Q 3 <br /> Date Service Completed (if already completed): SERVICE CODE: ' ^ p 7,' P I E: 7,30 3 <br /> Fee Amount: V7 1 0E) Amontt Paid Tia r Payment Dale h 1 1 tJ 3 <br /> Payment Type Ctil?e� Invoice# N / Check# D 17 Received By: +LQ <br /> EHD 48-01-025 A1'�VV 2-1' 3 b SERVICE REQUEST FORM <br /> RFVISED G-5-02 <br />