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SERVICE R2EQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Caas Z SRoo4o�a� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> �r0 <br /> FACILITY NAME <br /> AiRE ADDRESS 1\ ��� j'u7'p-•per`^} <br /> Street Number Dlredlon Slrcot Name CII ZI Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slrcot Number Street Nam. <br /> STATE ZIP <br /> QTY <br /> PHONE It1 E.T. APN R LAND USE APPLICATION# <br /> t2�) X2.3 ►3�1 <br /> PHONE t12 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR CHECK if BILLING ADDRESS <br /> PHONE# / Ext' <br /> EIusmEss NAME &S /?W <br /> FAXHOME Or MAILING ADDRESS 12 <br /> ( ) <br /> CITY STATE ZIP 2 <br /> L <br /> Lo L <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site anti/or project specific ENVIRONMENTAL HEALTm DEPARTMENT'hourly Charges associated with this project <br /> or activity will be billed to me or my business as identified on this IOnn. <br /> 1 .,ISO certify that I have prepared this application and that the work to be perlbrmod will be done in accordance with all SAN.10AUt11N <br /> COUNTY Orclinance Codes,Slantlarcb•,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATR' / -- <br /> PRoatarrY/BusINESs OwNICR❑ OPE.RKI OR/MANAGER ❑ OTIIEIt AOTuoitizi?OAGI•:NTp <br /> !/'ill�ruC:Nur i.x nnr rAe 61LUNfi Pdlq'Y. <br /> Proof gfauthorization to sign is required Title <br /> AUTHORIZATION TO RE1,EASE 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 Batu anti/or environmental/site assessment <br /> information to the SAN.IOAOUIN COUNTY ENVIRONMENTAL I-1EAU11i DEPARTMENT as soon sus it is available and ;It the same time it iS <br /> provided to me or my representative. . . n <br /> TYPE OF SERVICE REQUESTED: Lt i j <br /> COMMENTS: Pr \� <br /> 03 0 <br /> N V, <br /> U <br /> PN yOPPCNM�P'IM� <br /> p � EMPLOYEE#: ®3 Zl .N j ATE: / 2 30% <br /> ACCEPTED BY: ©Ltu�t � <br /> EMPLOYEE l{: $3 1 DnrE: 12, <br /> 3 U <br /> ASSIGNED TO: <br /> VICE CODE: N P I E' <br /> Date Service Completed (If already completed): SERjQtS a- <br /> Fee Amount: Amount Paid o 'l [ — Payment Date (x Bap <br /> 2-?cl•fJ c7 <br /> Check# Received By: <br /> Payment Type Invoice# pZ <br /> SR FORM(Goirlen Rod) <br /> EHD 45-02-025 <br /> REVISED 11/17/2003 <br />