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DECEIVED <br /> SAN JOAO" N COUNTY ENVIRONMEpi�AIZIjF.Ad. EppgTMENT <br /> SERVICE REQUEST ', ` y <br /> Type of Business or Property -F- SERVICE REQUE <br /> ST# <br /> C f HFA'yw f1PDARTtACh1T <br /> OWNER I OPERATOR <br /> CNECR H EI LING ADDREeso <br /> FACa1tY NAME <br /> 1 <br /> SITE ADDRESS Iql� Et t�xrrch �C1C7Q/ Jl(�(�TC� 21C) <br /> beet NU.W <br /> a <br /> HOME Or MNNG LIADDRESS (If DNFereId from site Address) <br /> street Number <br /> Cm STATE ZIP <br /> PHONE#1 Exr- APN# LAND USE APPLICATION# <br /> PHONE#2 �l:EmBOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BaiING ADDRESS <br /> BUSINESS NAME Et �qb a-ww -TM5 PNONE# Err. <br /> HOME or MAILING ADDRESS �K Vq V.,1�}att„`3xJAk1 FA%# <br /> J MY•p�r•H V�Y ( ) '4 ... <br /> CITY STATE'l. STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: '1�elp iI", DATE• �5'15 <br /> PROPERTY/BUS64ESS OWNER[] OPERATOR/MANAGER ❑ OTHERAUTIRORiZEDAGENT 1bLffiMWM1-VF, . <br /> IfAPPL/CA+r is nor the BILLING Pnxrr.proof of anthoriZation to sign is reqUirej rime <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 /> 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. r ` 1y, �{ i!, <br /> TYPE OF SERVICE REQUESTED: Q 1 b(LCI (�1 I 1+/ n (1,4 !/Y U. '(1/ v1.r lCJ <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SE ME CODE: P I E: <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Ref) <br /> REVISED 11/17/2003 <br />