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` t SAN O1� IN COUNTY ENVIRONML+NTAL HAWTri DEPARTMENT <br /> SERVICE REQUEST <br /> '`',';�w�:I'�:triness c•F'roert _._— --.. _. FACILITY ID# W_ SERVICE;REQUEST" -- <br /> bWNEIt1OPERATOR n� <br /> _____. CHECK i(Et]LLING ADDRES51�,� <br /> �F,CILITY NAME "5 ► } + - <br /> SITEi{DDRESS I I y I M'I � C4,p..`..____. t ����_0 <br /> 1 L o c <br /> Street Number Direction Street Name Ch ZIo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stre t Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> 30 --3633 <br /> I PHONE 92 Exr. BOS DISTRICT LOCATION CODE <br /> { ] <br /> CONTRACTOR I SERVICE REQ'UESTOR <br /> REQUESTOR <br /> CNECJC if BRLLING ADDRESS <br /> 13U51NES5 E1IAtN f �J !� FNDNE# � Exr, <br /> .If)-,AE or MAILING Aflt3RE55 FAX# �� <br /> r ) /- <br /> I tiITY STATE Zip <br /> BILLING ACKNOWL .DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific EW11RONMENTALHEALTH DEPARTMENT hourly charges associated with this project or <br /> a.:tivity will be b1led to me or my business a • identilied 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r� U <br /> " ( n it E SS OWNER 0 A-EkA e'OR:!i`.IANACF[t OT'."G};ai AUTHORI FO-ACENTV <br /> IfAPPLICANTs not th BILLING PARTY,proof of authorization to sign is required rifle <br /> AUTHORIZATION TO .LE F. INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby orize the release of any and all results, geotechnical dataaand/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: 1k 51C �kVOti <br /> COMMENTS: <br /> �.,-D <br /> DEC - 2 2004. <br /> USAN jOAQUIN hGH ' <br /> APPROVED 8Y: 'EMPLOYEE#:71 <br /> ASSIGNED TO: V\. Ol EMPLOYEE##: � 1 DATE: !�J b <br /> A. <br /> Date Service Completed (if already completed): SERVICE COD PIE. , <br /> Fee Amount: J� Amount Paid0,11Payment Date d <br /> Payment Type Invoice# Check# Receiv d <br /> EHD 48.01.025 <br /> SERVICE REQUES40RM <br /> R1=%ncr:n r_S.ng <br />