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07/28/2003 16: 10 4640138 ENVIRONMENTAL HEALTH PAGE 04 <br /> SAN JOAQuIN COUNTY ENVIRONMENTAL DEAL L H DEPARTMENT <br /> SERVICE REQU1CST <br /> Tv of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C4S bio r. O )v-3 r 5� �%5( <br /> OWNER I OPERATOR n <br /> 1 ,r/f y�elrO%e 4'-P" <br /> FACILITY NAME /� <br /> CHECK If 81LLIfJG ADDRESS t«�] <br /> /'/� ,ly[ <br /> d eun7 <br /> SITE ADDRESS <br /> 0., <br /> 2 qk P, L� <br /> Sheat Number Direction Xe Street Name C Zip Code <br /> HOME or MAILING ADDRESS (1f Different from Site Address) 2-0vc/I0 a <br /> 30/0 / D LL Y Strgct Number Street Name <br /> CITYSTATE QIP <br /> /-/1 tl� ,, <br /> ' 9l 301 y31r <br /> PHONE#1 EKT. APN# LAND Usi:APPLICATION# <br /> (Z-oy) '�df- 31.2- <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BtLLING_ADt)BE�� <br /> BUSINESS NAME/ PHONE EXT. <br /> e.'icL'o�st�K�tia•` vts S"16 <br /> HOME or MAILING ADDRESS FAX# <br /> 3 Fi.rr ,Ir. A4Z 3 ( 1st sits s b'SS� <br /> CITY STATE � ZIP <br /> BILLING ACICNOWLEDGFMF.NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-TEALTI-I DE;PARTMI_NT hourly cllargcs associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify tint 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes.Snrndcrrds, STA'L'Eand Fi=InC:IZAI-laws. / <br /> APPLICANT'S SIGNATURE: / ��"1 DATE: <br /> t� <br /> PRt)P'FRTV/BININI.SS OWNER 13 OPERATOR/MANACr it 13OTItrit/At)TIIORIZBb AGGNT Liz / BrQdrL b w <br /> //'Ahr1UCANT is ani the BILLING AIR7T,proof of aitthorizafion rn sigu is rcryuireeI T1rle <br /> AUTHORi7ATION TO RET,E.ASE INFO'12MATTON: 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 /> informa(ioh to the SAN JOAQUIN COUNTY T:NVIRpNMI'-NTAL HEAI.Tit DrPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or my representative. my-MEM T <br /> TYPE OF SERVICE REQUESTED: j 4RECEIVED <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVCD pY: EMPLOYEE#: 7 , IIATE: D A 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE. p� Pi E: /G( <br /> Fee Amount: C Amount Paid Payment Date '7 l <br /> ' L4 71 <br /> Payment Type v! Invoice IY Check# Ree lved By: <br /> EHD 48.01.0250 )a2 j /(( � SERVICE REQUEST FORM <br /> tzevlSt'n r,-r,-n? 91i& <br />