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SAN JOAQ^ 1 COUNTY ENVIRONMENTAL HEA.^.I DEPAIYPMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID N SERVICE REQUEST N <br /> SACC' � j% jI <br /> -QYVNER OPERATOR IV Lf <br /> A16� 12 A � � CHECK If BILLING ADDRESS <br /> X- PC <br /> r <br /> - <br /> D I//� ,/� Pjtfk` ' 4OC <br /> $., ( � G �5 /�..Cc <br /> ZI CWeNumber DlraclionLING ADDRESS (II Different from Slle Address) r ',r 2Street Number M Vr IretName leD STATE ZtPq�32SC �L o ti e-� (� <br /> Ext. APN N LAND USE APPLICATION# <br /> PHONE N1 O /� 0^ 0 6 <br /> ( ) LOCATION CODE <br /> PHONE N2 EXT. BOS DISTRICT <br /> l ) <br /> CONTRACTOR/ StRVICE, REQURSTOR <br /> REQUESTOR CN CKif BILLING ADDR SSp <br /> PHONE Ear. <br /> BUSINESS NAME / <br /> HOME Or MAILING /DDRESS 4NL "X'0 FAX IL <br /> STATE ZIP <br /> CITY <br /> it I r , ; <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 HEALTII DFPARTMEN'r hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on[his form. <br /> I also certify that I have prepared this application and (lint the work to be performed will be done in accordance with all SAN JOAQUIN <br /> OUNTY Ordilmnce Codcs,Standards,STATE and FL•DERAI.laws. { ^� <br /> DATE: <br /> PPLICAN'I'•S SIGNATURE• ���1)11111A <br /> � — <br /> p' <br /> iI1D1'EItTY/BnslNhss O1YNEIt C. - MANAGFIr ❑ L71'IIRa A(ITIIDINZFD AGENT GJ/ H <br /> /f APPLICANT is not the QII.I,ING PARTY,proof of euthorizefinn to sign is required - Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properly 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 1OAQUIN COUNTY ENVIRONMENTALL,HEALni DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O-LV/ <br /> COMMENTS: /� %. I -/.y_"/1.•.n...l 3I/OEV E <br /> / �o <br /> 6 � 40 s pYSIN GOUNTr <br /> SPUBLICOHE UREA RH D VSSION <br /> APPROVED BY: EMPLOYEE N: ATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> N <br /> Dale Service Completed ([f already completed): SERVICE CODE: PIE. <br /> Fee Amount: y AmountPaid , Payment Date a'� 03 <br /> Payment Type Invoice N Check N /q')33 Received By: <br /> SERVICE REQUEST FORM <br /> EHD 40-01-025 <br /> REVISED 6-5-02 <br />