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JAN JOAQUIN I,OUN'I Y V NVIRONMEN'I'AL MEAL IH IIEPAKI'MEN I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> dobb3 ?� <br /> OWNER/OPERATOR <br /> -pf\IJ VArJ PrP-OrJIr3Ge:nJ CHECK If BILLING ADDRESS® <br /> FACIury NAME VA(-j &A2-0�J1i%J6-L71J PP-OPE?-T\( <br /> SITE ADDRESS 1 SII;0 ' S I J t\L-TO N C P-IA tvtRnr+E�A 9 r 336 <br /> Street Number I Dirm,tion Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAMC Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EST. APN# LAND USE APPLICATION# <br /> (209 ) R82- Szy 203 - o(oo -13 PA - 1 -2-(50,Z 2— <br /> PHONE <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR 1�Ac-c o CHECK if BILLING ADDRESS❑ <br /> ftP�P�y <br /> BUsINEsSNAME t�IJE O-Pclt_ V�ET�..1U1 P-aN M'1 F.NYf�L PHONE# En <br /> tory 3V`i o3�r <br /> HOME or MAIuNG ADDRESS FAX III <br /> S{0OAlL ST. (201) 3(0-1- 03' <br /> CITY LPD11 STATE CA LP 9T7-`FO <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 HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 Codes,Standards,STATE a d FED; ws. <br /> APPLICANT'S SIGNATURE: 4i46DATE: ( - 10 -13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/4ANAGER ❑ OTHER AU IHORIZED AGENTS! e MSV(47y&s <br /> IfAPPLICANT is not the BILLING PAR 7Y 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 ENviRDNMENTAL 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: JZF_tI 1 Ew S''Ot f- S'VTT1°1'C31 t-fly MDy <br /> COMMENTS: <br /> (7viAe,- koP P,(¢�ct:d I�,r l/i2�+� - w-#4-11A SAOCXPb2-4-7 dee ,44,- [a.e.() . <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: 'z� P I E: . <br /> Fee Amount: 2� `� Amount Paid �O.UI� Payment Date <br /> Payment Type Invoice# Check# ;1110-0 Received By: i_T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />