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SAN JOAC,`' COUNTY ENVIRONMENTAL HEA. : DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> 5/ oo -(ai yo <br /> OWNER/OPERATOR <br /> ✓Q; 1 � �R C7 _SS� CHECK 1(BILLING ADDRESS <br /> FACRrrY NAME /� <br /> SITEADDRESS 9 ,-t 415- S, �,I.PMYy ISG` , AY1'VL'Vic'Vy� <br /> Street Number I Diredton Slmel NameCit,3 Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( toq) 993- 6435- 0"3- 332 <br /> PHONE 92 EST. BOS DISTRICT LOCATION CODE <br /> J ,•' CONTRACTOR <br /> NTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1�AV 1(� W Q,�GVH CHECK If BILLING ADDRE 5 <br /> V <br /> BUSINESS NAMEI�YPRONE# EaT. <br /> N�1 td� rs avt r ,�c ot. 3 m k- 39 0 <br /> HOME or MAILING ADDRESS FA%# <br /> zv 1 (lddl) 3&9- 42-7-2 <br /> CITY 1 _6; STATE CA ZIP CIS2-4r) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 Cortes,StandrJ , T�E/and <br /> /jFEDERAL laws. / //[/a,7 <br /> APPLICANT'S SIGNATURE ISL�C Y l�1\r� DATE: l � � 07-S <br /> � IIqq <br /> PROPERTY/BusINess OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT rp <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII 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: SOle- PA IVED. <br /> COMMENTS: C.ct.P,P �- �� 2003 <br /> �IeuSe rJev�trw �Ac.. tv��lote`��- - <br /> vfF cx Inn� a v� TT u ✓ ?I(p 1 rr7 ' �( counf(Y <br /> -)1.-) CX <br /> Ihr 7•�� Y r I ,,,.,� SHFJd-TNDEPA TM T <br /> 0 <br /> APPROVED BY: EMPLOYEE#: 96 9 DATE: (� aJ <br /> ASSIGNED TO: n &SGO1� EMPLOYEE#: �l�il DATE: �l : 35 6 3 <br /> Date Service Completed (it already completed): SERVICE CODE: of ZZ PIE: '�(00 <br /> Fee Amount: /d& p U Amount Paid r/ w v� Payment Date �� zd' 03 <br /> Payment Type Invoice# Check# ` �,Z S� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />