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C <br />S:;N JOAQL COIIN'I Y ENVIIZONMEATAL HEAL. DEPART'iMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST i) <br />BUSINESS NAME ' <br />i C:^INS I OPERATOR <br />� -- — � — <br />CHECK If BILLING ADD ESS <br />��_` <br />FACUTY rAME <br />II SITE f1D0R'tSS�--��-D��v <br />�J <br />Street Number <br />Or MAILING ADDRESS (If Different <br />Direction Street Name Cit 7iiFCode <br />from Site Address)treet <br />rn1E <br />Number Street NameY <br />STATE ZIP --- --_� <br />P;IDNE #1 <br />l <br />Ex` APN # <br />LAND USE APPLICATION # <br />II <br />r <br />PHONE #L <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICI, REOUP,STOR <br />R.EQUESTOR -- — <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME ' <br />PHONE# ExT. <br />LOT <br />H ME Of AILING DDRESS <br />FAx # <br />CITY —STAT�h <br />zip T�-2Q <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same• <br />atknovv]Cdlle that all site andlor project specific ENVIRONMLNTAI, IIFALTTI DIiPARTMENT hourly Charges associated w!th this proiccl c <br />I'Alvit", will be.billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOA(?U!N <br />C -)UN I'Y Ordinance C'orles, Staifrlar(ls, S1' "I. and FEDERAL laws. <br />a1'P1.1�AN�; 5= DATE• 2` 04�`J _— <br />/ Pltu Fa �I3uJ:INI•ssOwNFR )VEurrolt/MANAGER UTl?It Al'fll(R7t:D AGENT <br />Tj /i77Tr(-ivy`r"llr.l.11CP/II(l ❑ <br />— <br />Y• proof (/f atrthorizatiurl to sign is , egtrired Tule <br />Ati'I'lf0IZIAA'I'ION '1'0 REI,FASE IN FORMATION: When applicable, 1, the owner of operator of the property located at tl:r <br />a .Iv,. site address, hcleby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />Information to,lhe SAN JOAQUIN COUNTY LNVIRONMENTAL- 1-II.W.-TI! DEPARTMHN r as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERViC€ REQUESTED: C(- S T— <br />Copt 1MENTS:(�����/Gl� �et� <br />94/' <br />LAYMEN -7 <br />POW -P zrrt Ar <br />FEB 2 4 2005 <br />SAN JOAQUIN COUNTY <br />t ENVIRONMENTAL <br />HEJ•1LTH DEPARTMENT <br />i APPROVED BY: ---� i EMPLOYEE #• q(, q j <br />q %q EMPLOYEE #: <br />ASSIGNED TO: `f <br />�.���� <br />Cate Service Completed (if already completed):— j SERVICECOODE: �J <br />Fee Amount: �qCC, Amount Paid —� Pa my ent Date <br />Payment Type—�✓' Invo ce # Check ith—� / <br />ErID 48-01-025 <br />r .—VISFD 6-5 02 <br />DATE: <br />DATE: <br />PIE: <br />i <br />"'? � / <br />Received By: <br />SERVICE REQUEST FDRivi <br />