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SAN ,JOAQUIN (',UN'I'Y ENVI1tONMLN'I'AL H1;ALTI �11sPAK'1'Nll✓N'1' <br /> SERVICE REQUEST `f <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Mb--r- && •.S'(\GO 3 - 981 <br /> OWNER/OPERATO <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> r 0a rel wed > <br /> SITE ADDRESS 3 <br /> Street Number Direction Street Name City zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 _ �,�� f brl/I <br /> SlrceI Number C t.�lJ(.JCJCS S1reCetlN e <br /> CITY i ` STATE ZIPS <br /> PHONE#1 EX APN N LAND USE APPLICATION b C' <br /> (":olf ) 09Z-19PA—D-2--10?, <br /> PHONE#2 EXT. - �%%-��� BOS DISTRICT LOCATION CODE <br /> ( �`l ) 3 165- -7o� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESSC] <br /> BUSINESS NAME PHONE# EXT. <br /> HuLlhes Hard W of 365-7C>1Y <br /> HOME Or MAILING ADDFIQ FAX# <br /> Wccxj AU ( Zo`,) Ci 31— 6 <br /> CITY STATE ZIP <br /> BILTANG ACKNOWLEDGEM sNT: I, the undersigned property or business owner, operator or authorized agent or sante, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-113-ALTII 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 thiication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stab ards,STAT and FEDERAL laws. �J <br /> APPLICANT'S SIGNATU]Rr. DATE: .Z2,63 <br /> PROPERTY/BUSINESS OwNEK I'ERATOR/MANAGISR 171 OTHER AuTnomziiD AGENT 11r11 <br /> IfAUCA Tis not 1he BILLING PARTY,proof of authorization to Sign is required Title <br /> AUTHORIZA'T'ION 'I'O RELEASE INFORMATION: When applicable, I, the owner or operator of(he 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 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: It <br /> COMMENTS: ��/ � � ���oo3 <br /> oJzX- e#"-� SAN 30NC"j\VACID HSEFN�N15�ON <br /> rp4/N^� SNN�NMSNSA�HF.P�- <br /> APPROVED DY: (,YtkkALQ <br /> EMPLOYEE#: 2Z DATE: U -- I l:) <br /> ASSIGNED TO: Lt j-vL EMPLOYEE#: r 6` DATE: V .� <br /> Date Service Completed (if already completed): SERVICE CODE: 5 Z P I E: X00 <br /> Fee Amount: 5 P9Amount Paid Payment Date �?/at c)J <br /> -'went Type Invoice t! Check# -717,S-- Received By: <br /> A-01-025 SERVICE REQUEST <br /> .SED 6-5-02 <br />