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SAN JOAQUIN COUNTY ENVIRONMEN UERE�TH DEPARTMENT <br /> SERVICE REQ SERVICE REQUEST# <br /> FACILITY ID# C e of Business or Property S C)UD(/_ 3q <br /> c s s � <br /> LA0S�C <br /> CHECK if BILLING ADDRESS <br /> MINER I OPERAT L^ n M �7 <br /> FACILITY NAME l- \ ^ ICC ��SC L� CGlQs <br /> "'-GfG//�� <br /> Ci <br /> SITE ADDRESS M(,uiU IFY /Setae N <br /> 1 to V Street Number W ection / — [� <br /> d //0 2 <br /> HStt Number <br /> OME or MAILING ADDRESS (if Different from Site Address) , treat Name 7 <br /> reeC�Q <br /> SS <br /> STATE G e zip 7J V <br /> Cl liLANp•(ySE PLICATiO1 0 ()L ( ' <br /> EXr. APN1_ISG (o Y JL/� <br /> PHONE#1 7 C 9 / <br /> BOS DISTRICT LOTION CODE <br /> ExT. <br /> P2U9 ) �Z/ - z(cc��2 <br /> TRACTOR/ SE VICE REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> REQUESTOR <br /> � <br /> �j PHONE# Exr. <br /> BUSINESS NAME DOS �vl!i' y- A <br /> 10C_) FAX# <br /> HOME Or MAILING ADDRESS ( ) <br /> CITY C� / Z STATE zip <br /> BILL G ACKNOWLEDGE ME the undersigned property or business owner, operator or authorized agent of same, <br /> actinoledge that all site and/o Ject Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity be billed t 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 Codes,Standard&STAT�Ean L FEDE L laws.APPLICANT'S SIGNATU]Rf{ OC G? DATE: <br /> PROPERTY/BUSINESS OWNERS —OPERATOR/MANAGER OTHER AUTHORIzED AGENT O/ill"e-1411 <br /> If APPLICANT is not the BILLING PAR Tr proof of authorization to sign is required Title <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 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: N['T7Zv�'I-E l.-f7 q-O/nl(y- SO 1 L <br /> COMMENTS: -7 -/� / ( ,r�,,,�,-•7 �-- EIVED <br /> y JUL 1 2008 <br /> SAN JOAQUIN COUNTY <br /> IEWV' r`(J��-� AIG3 C.� HEALTH DEp E�'� <br /> ACCEPTED BY: �t--( ,c_l .a �f_ EMPLOYEE#: 3• DATE: bkY <br /> ASSIGNED TO: --- zSI D��Z)LLI,QS EMPLOYEEM C(- -s DATE: zll 0h <br /> Date Service Completed (if already completed): SERVICE CODE: ;j ZS P I E: z(Qgj Z <br /> Fee Amount: T 4 U, Amount Paid q q?77 '- Payment Date © S- <br /> -Payment Type Invoice# ( 0(77-I Check# Received By. <br /> REDVISEDZ-026/f T/2003 C �I-7�IR�4�G/J c`� SR FORM(Golden Rod) <br />