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SA'N' -'QUIN COUNTY ENVIRONMENTAL HEAL, d DEPARTMENT <br />SERVICE REQUEST. <br />Type of Business'or Property FACILITY ID # <br />; . SERVICE REQUEST# <br />OWNER /OPERATOR ' <br />C PSI? D. l Yi VesYrnenfi Inc;) CHECKif BtLLtN=ESS <br />._..�✓ I.� <br />Street Numb <br />e�Direction """' I S D- 'Ill G�i� I52'S <br />treet Name <br />NOME Or MAILING ty <br />ADDREss (if (Diifferent from Site Address) . zi code <br />• Crrr. StreetNumber' freef Nam@ <br />Ltd iSEA <br />/} <br />WDPHONE#1 Err. .. "/� <br />APN #' LAND.USE APPLICATION'# <br />TO l /,00 3 <br />.PHONE#2 `. E)r. <br />I <br />BOS DISTRICT 1 Z LOCATION CODE <br />CONTRACTOR 'I SERVICE- .REQUEsToR-.... <br />REQUESTOR <br />.CRECK if BRIJN•_ G ADDRESS . <br />BUSINESS.NAME <br />PHONE Exr. <br />Hones or MAuuaG ADDRESS <br />FAX# . <br />C ( �.._ <br />5TL 7:11A STATE Tip <br />BILLING ACKNO�I,EDG <br />EMEIVT' I, the undersigned property or business owner.,' operator. or authorized agent of same, <br />acknowledge that all site and/or project specific $tJVIItoNroENTnL HEALTH DEPARTMENT hourly charges. associated with this project <br />or- activity will be billed to me or my business as identified•on this forni. <br />Ials0. certify.that i have.prepart d this application and tbatthe work. to -be performed.wili:be done in accordance witli.all SANJOAQUjN <br />COUNTY Ordinance Codes, Standards, STATE and FEDBRAL laws. <br />APPLICANT'S SIGNATURE: <br />lz!�' �J bAXE* 10 <br />Pk6.ERTY/ BUSnWM 0WNERC7 --� c` J� <br />OPERATOR'/MANAGER 0 OTEMR.AUTHORU DAGENT�. TITTT <br />I)rAPPL!C.iM is not the BILLING PRRTP proof of authorization 10 sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFO- NlATIQN: When applicable, 1, the owner or. operator. of the.property located at the <br />above .site address, hereby authorize the release any .and all results; geotechnical data and%r.environmenterty l assessment <br />informatlnn to the S AN.:TOAQUIN COUN3 Y ENVIRONIvIENT,gI HRAT.IH DEPABTMDrf •as soon as itis available and at the same time it is <br />`provided tome or my representative <br />TYPE OFSERWICE REQUESTED: <br />...' __..._COMMENTS: <br />OFp Art, <br />EMPLOYEE#: Dare. <br />T / tO <br />ASSIGNEa T0: <br />6A - EMPLOYEE #: <br />DATE: <br />.Date Service Completed (if already completed): �03 6 <br />SERVICE'CODE: P. / E: <br />Pee Amount l.. p <br />AmounfPaid 3t1[ D :Payment:Date <br />Payment Type Invoice #�/ (7 <br />Check # R <br />�. eceived By: L16 <br />EHD•4S-02-025 <br />REVJSED 11/77/2003 SR FORM (Golden Rod) <br />