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,7)AIN Jk1/i..QU(PI %—UUIN IT "NV 1lCtllV IYI L'lW 1 HL ILLI/lL 1 Cd Ap,1L.1"lt 4C 1 IYI IrII 1 <br /> SERVICE RE'QU E+s,r <br /> [0) <br /> ype of Business or Property FACILITY Ill# SERVICE REQUEST# <br /> VVNER/CO)Pl;RAT0R <br /> CNECIC If-BILLING ADDRESS El <br /> FACILITY NAME <br /> ,,ITE ADDRESS <br /> Street Number Dlrnetlan Strout Name CI Zip rude <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stroul NumI,. Street Name <br /> Can STATE CA Zip ?,3z3 Q <br /> PHONEIN EXT. APN 0 LAND USE APPLICATION It <br /> Q55T 59,3 3 2— <br /> PHONE 112 EXT. BOS DISTRICT LOCATION CODE <br /> CON` RAC'rOR 1 SERVICE REQUESTOR <br /> RrQUcSTOR CHECKif BILLING ADDRESS <br /> SUSINESS NAME PHONE# <br /> G <br /> HOME or MAILING ADDRESS FAxIt <br /> l 1 - <br /> CITY STATE ZIP 5 <br /> BILLING ACKNOWLEDGEMEN'r: 1, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project speciFtc ENVIRONMENTAL HEA.LI'1.1 DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to isle or Iny business as identified on this furan. <br /> I also cerlily that 1 have prepared this application and that the work to be performed will be datic in accordance with all SAN.IOA()IJIN <br /> COUNTY Orcftlrcince Co&,.s,SlcrnrIcirds,STATfi and FLDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE. Z � S <br /> P'itoPERTY/BUSINF,SS OWNE..a❑ 01'FRATOR/IYIANAClitt ❑ O'nimt Airrlioitizim AGI'.N'1'❑ <br /> 1f'1l1'1'L1C.•fNT is not the 811,L10;PARTY,proof of utit tori ation to.I7gn 1.1 required Title <br /> 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 anti/or environmcntal site asscssmunL <br /> itil'ormation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HrALI'H DuARTIVI NT as soon as it is available and at the°falTlu time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PL <br /> s E�o ao el?�M�� <br /> 1= <br /> ACCEPTED BY: 1 MPLOYEEft: HATE: <br /> ASSIGNED TO: f EMPLOYEE f: DATE: d <br /> Date Service Completed (if already cornl)leted): SERVICE CODE: P r F <br /> Fee Amount: Amount Paid Payment Date (L �p <br /> Ea:ym:e�ntType � Invoice# Check# � Received <br /> EFID 48-02-025 SR FORM(Grilden Rod) <br /> REVISED 3111712009 <br />