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SAN JOAQUIN OINTY EwntoNMENTAL HEALTFI DEPC)ENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />_ , ` <br />'jCHECK ifB[LLINO ADOREss19 <br />am <br />SERVICE REQUEST to <br />AS STP.M00 3-7/ <br />PHoxEl zj 3 — g gXT• <br />d 100 <br />3`1S <br />OWNERI OPERATOR - <br />FAX# <br />.f7 <br />{4bt s oV 3 " 4 6a(p <br />IIww <br />CHOOKifBILUNGAoonesa❑ <br />FAcILnYNAME' `QAJt'bV1 <br />SITEADDRESs <br />331 <br />-atreetnumbar <br />6 <br />1/-fo ivy Sf . <br />SetMCECODE: - <br />Pie: a <br />Fee Amount On <br />Atltount Pald(l <br />Irccibn <br />Slee <br />Payment Type ✓ Invoice# - - <br />Check# <br />D <br />HOME or MAILING ADDRESS Of Different from Site Address) <br />Street Number <br />Street Ne a <br />Cm <br />STATE zip <br />PHONE#t - EXT. <br />APN# <br />LAND USE APPLICATION# <br />(AM) .2313 <br />PHONE02 - ExT. <br />IROS DISTRICT LOCATION 000E <br />CONTRACTOR I SERVICE REOIIESTOR <br />REQUEs <br />µ <br />_ , ` <br />'jCHECK ifB[LLINO ADOREss19 <br />am <br />BUstNEss NAME5 <br />COMMENTs:5t^_f^..'w Ut b'Q.m <br />it'Ls�-y7�r,1[�,{L�Ii�I.LG..IJ�- oA,_evu <br />'YI..CA <br />_.IA.G •VK, A, Ja✓t 'an+ Ja.ue. up9roJe, Yv�.ay <br />PHoxEl zj 3 — g gXT• <br />d 100 <br />HOt�OrMAIUNGADDRESS t) ` , /' <br />EMPLOYEE* <br />FAX# <br />.f7 <br />{4bt s oV 3 " 4 6a(p <br />c t'� <br />CnY JQ.6'i, C1Dia-Q. - <br />STATE LF zip 4s() <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized Agent of same, <br />acknowledge that all -site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 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 Codee, Standards, STATE and FEDERAL laws. /9/ <br />APPLICANT'S SIGNATURE: i .f..t� b��-�f--2C 2t�-6-clJ DATE: ,r 16 l Za dw4 <br />� , <br />PRomw/Busmmowmm[3 OPERATOR/MANAGE❑ OTI=AUT'HORUNDAccvx�(1eMDfi&(e, c'pW�tUIQ'6oV <br />#f4PPLIC07 is not the B?LINGPARTr. proof ofauthoritafion roskn is required Tine <br />AUTR0TtI7ATION TO RELEASE Rg ORMA.TTON: 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 cnvironmentallsite assessment <br />information to the SAN JOAQUiN COUNTY ENVIRON ENTAL 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: 0 , <br />PP <br />COMMENTs:5t^_f^..'w Ut b'Q.m <br />it'Ls�-y7�r,1[�,{L�Ii�I.LG..IJ�- oA,_evu <br />'YI..CA <br />_.IA.G •VK, A, Ja✓t 'an+ Ja.ue. up9roJe, Yv�.ay <br />a vA -hcv: kK - <br />bt_ WZtx1vV,0A <br />PIG, <br />gPN NSP <br />� TN <br />ACOEPTm-BY: <br />EMPLOYEE* <br />DATE: _ _ <br />AssIQNEDTo: -Dan r) C <br />EMPLOYE£#: <br />DATE: O � 1-7 <br />Date ServlCa.Completed (It already completed): J <br />SetMCECODE: - <br />Pie: a <br />Fee Amount On <br />Atltount Pald(l <br />Payment Dam ko1\1 O <br />Payment Type ✓ Invoice# - - <br />Check# <br />D <br />Received By. <br />END 48-02.028 <br />REVLSED 1111712003 <br />SR FORM (Golden Rod) <br />1lbs <br />PE��� <br />