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SAN JOAQAgh"COUNTY ENVIRONMENTAL HEADEPARTMENT <br /> SERVICE REQUEST <br /> Ty of Busine or Property FACILITY ID# SERVICE REQUEST# <br /> FA000757/ S�op3SSz9 <br /> OWNER I OPERATOR <br /> i <br /> C CHECK If BILLING ADDRESS <br /> FACILITY NAME t `s <br /> SITE ADDRESS !!// �//q��" <br /> Street Number ecllon �I )Lr heel Narrk � 7 l-/ Zin Code <br /> HOME or,MAILING ADDRESS (If Different from Site Ad r ss) <br /> Street Number beet Name <br /> CI TATE ZIP <br /> & i6lOa= <br /> 0 E 1 <br /> EXT. APN# LAND USE APPLICATION# <br /> PN <br /> EXT. BOS DISTRICT LOCATION CODE <br /> m7—oz?,I <br /> -CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM pli <br /> ✓{J�' <br /> HOME Or MAILING ADD ES.� ` FV)q ?c/ <br /> CI <br /> L^- J <br /> v <br /> CITY STAT �C1� ZIP <br /> BILLING ANOWLEDGEMENT: I, the undersigned property or business owner, operator or author✓ized agent of same, <br /> acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTII DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my bu ' ess as identified on this form. <br /> I also certify that I have prepared is application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Stand Ifl� T /E.and FE�I[(/tr�h laws. <br /> APPLICANT'S SIGNATURE: T. 4 / X ,/�/✓/ DATE:: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> 1fAPP1.ICANT is not the BILLING PARTY 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 /> infomtalioti t0 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. pAXEN-1 <br /> TYPE OF SERVICE REQUESTED: asr '2.UG/yam RECFw <br /> COMMENTS: ocY 2O� <br /> P'N JOHEw1115E'Rk f Imo, <br /> fN`ARCt;I:01t N.l^autdL�N 9tV� <br /> APPROVED BY: /� EMPLOYEE#: '5CQTV DATE: OG a <br /> s l2' <br /> ASSIGNED TO: EMPLOYEE#: 3ST0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Me PIE:�3Q <br /> Fee Amount: QV Amount Paid —171490 Payment Date /0/62& 0� <br /> Payment Type Invoice# Check# �7��3 Receive <br /> EHD 48-01.025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />