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, I <br /> SAN JOAN COUNTY ENVIRONMENTAL HEAL'OEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> _ q SERVICE REQUEST# <br /> SOIil�le �' In GI, BO to <br /> OYIMER/OP TOR <br /> CHECK ifBIWNGAnDRE55® <br /> FAa IIAIy�, C}0. -� loS <br /> SrtEADDeEs1`s1n� <br /> 50� so-eee Num». D seso� <br /> StrMt Nam city <br /> HOME Or MAILING ADDRFSC <br /> Codi <br /> IN Different from Site Address) <br /> 301 I <br /> (y��rv- �E arnat N.,n. <br /> Tr z,Aro- yi IIS 1t j/3(7 � <br /> H JESI APR# LAND USE APPLICATION a <br /> p <br /> , OIO )��5 �W . <br /> PaoIE R En. <br /> BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REO a nc v-xY raS CHEcK ff BuuaG ADDRESS❑ <br /> � - <br /> BUSIMEss Nalr <br /> /j m o i W1 PHONE# 5 S• 15� . <br /> HOMEGo[MAILNGA SS FAx* <br /> o()l1,113 e� 54' 1559 ) S33-"Sa <br /> CRY n rte STATE(:� zip <br /> ) <br /> BILLU4G ACKNOWLEDGEMENT: 1, the undersigned property or business owner,loperator or autiorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMFNTAi. HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will he billed to me or my business as identified on this lixm. <br /> 1 also certify that I have prepared this application and that the work to he performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codec,Standards,STATE and FEDERAL laws. Q <br /> APPLICANT'S SIGNATURE: Li 1-)0 t"}S DATE: <br /> PROrFRTV/BUSINESS OWNER1Lt OM:BATOR��/MANAGER ❑ OTHER AtIMORInDAGEM❑ <br /> /f APPL/CAN✓T✓��is not the BILL/NG PARTY Proof of authorization to sign is regaimd Fitt, <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 and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY FWiRONMENTAL HFAI TH DEPARTMENT as soon as it is available and at thes11e time it is <br /> provided to me or my representative. AYMEN 1 <br /> TYPE OF SERVICE RizoumED: <br /> COMBOS: <br /> NCL,iJQ— SAN JOAQUIN COU <br /> "V <br /> DEPARTNIE tT <br /> ACCEPTED BY: E#: DATE: //-06-o <br /> ASSIGNED To. �'/ EmPLAYEE#: DATE: <br /> Date Service Completed (if already eortlpkHad):( I)n lin LU hf SERNLE CODE: <br /> Fee Amount Amount Paid <br /> '9>,�-7q, OLD) Payment Date I I le 0 <br /> Payment Type ✓ Invoice# <br /> Chedt# D S�Z&I Received By: <br /> EHD4 <br /> REVISED ED 1111 11/172003 SR FORM(Golden Rad) <br />