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' r "-.�.--..��.+..a ua�ru�vi�iraui�lHL iiGtil.Ari Lli.YA1t11V1�;N'I• - <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />f�D00 `i3 SR�a st�9d8 <br />",- - 0WNER10PERATOP( <br />`-'( CHECK if BILLING ADDRESS D <br />FACaITY NAME <br />�--- -SITE ADDRESS — - - <br />SlreetNiimber Direelion Stre me CN t Code <br />HOMEor MAILING ADDRESS (if Different from Site Address) <br />umber Street Name <br />CITY STATE .. LP <br />PHONEtit - APN i! LANnUSE APPLICATON# <br />PHONE#2 fir• - - SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE <br />Q UESTOR <br />. - <br />REQUIE5TOR <br />,Xyd= - - - CHECKif BILLING ADDRESS <br />Y <br />NAME' EK <br />HOME or MAILING ADDRESS F <br />en <br />Crrv- ,_ STATE. (� ZIP <br />v1 <br />95 <br />Ne BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or, authorized agent of same, <br />' acknowledge that all site and/or project specific ENVRONNIENTALFIEALTB DEPARTMENT hourly charges associated with this projector <br />' tt <br />». activity will be billed to me or my business as identified on this form. <br />r . 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 ]a rs: <br />APPZICANT'S SIGNATURE: DATE: - <br />�. s,'` Pnorauu`r'Y/BusrnEss OwNeR❑ Orr:RA7oR/MANAcIeJt �. Avraowzeo <br />AGFxr <br />__ _ , _ fAPPLICgNT is notthe BJLLTNGPAR77:proofofauthnriZatioa to sign is <br />requireal Title - <br />-' AUTiIORIZATION TO RELEASE INFORMATION: When, applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the ze]ease of any and all results; geotechnical data and/or emrironmental/site assessment <br />��-. 1nfOIIDatiOn to the. SAN JOAQUIN COUNTY ENVRONbfENfAI. HEALTH DBp,1gTMENT as soon as it is available and at the same time it is <br />� p"roanaedTome or my representative. <br />TYPE OF SERVICE REQUESTED: PAYMENT <br />r, -- <br />- DEC - 4 2009 <br />y - SAN JOAQUIN COUNTY <br />ENVIRONMENTAL. <br />HEALTH DEPARTMENT J ACCEPTED BY: EMPLOYEE#:�°'��n'DATE: / 7 U :7 <br />EHD 48-02-025 <br />�' REVISED 11/17/2003 <br />SSIGNEDTO: <br />EMPLOYEE#: <br />r v <br />DATE: <br />r# <br />ate'Service Completed (if already completed: <br />[Fee <br />- <br />.SERVICE CODE / - <br />PIE., 'T - <br />Amount: Q` <br />Amount Paid <br />3 �, S� <br />Payment Date - �Z a <br />' <br />Payment Type ✓' <br />Invoice #. <br />Check # ? <br />Received By. <br />EHD 48-02-025 <br />�' REVISED 11/17/2003 <br />