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SAN ,T OAC --N COUN'T'Y ENVI IZONNI EN'I'AL I-ILf+ '-1 DEPAlZ'1'M1",N'l' <br /> t t <br /> SERVICE REQUEST <br /> ";pc cf Business or Property FACILITY ID# SERVICE REQUEST # <br /> ( 7/5 <br /> OWNS ATOR <br /> LS <br /> If BILLING ADDRESS I <br /> /'Vi/It7'� <br /> { FACILITY NAME a <br /> If <br /> �c,�lr4,ti1C 2x� <br /> i <br /> Street Number Direction Slrecl Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE 91 EXT. APN # LAND USE APPLICATION <br /> iP-ONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU STAR <br /> Q� CHECK if BILLING ADDRESS L� <br /> ( F <br /> BUSINESS NAME PHONE# <br /> E or MAILING ADDRESS FAz2j; ) �C <br /> iC;TySssR_ 1�_ \ STATE ZIP 4jS'"'.� <br /> Lr <br /> B11.1INCGKA�1CKjNZOW1.EDGENIEN'I': I, the undersigned property or business owner, operator or authorized agent ul' sarnci, <br /> :t,knowledge that all site and/or project Specific ENVIRONMENTAL l-IEALTIi DE.PARTMfN'I'hourly charges associated with this project or <br /> activity will be billed to me or u1y business as identified on this form. <br /> 1 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 /> CUUNITY OrdillcHlCe Codas,StrHU1111 IS, STATF and 1'L:DERAI.laws. <br /> APPI.ICAN'I"S SIGNA'ruimWdj�9 tge DATF: <br /> Ilaoi't:ItTl'/ BusiNF.ss OWNF:It❑ l)PERATON/NIIANACER OTlllilt AU'riioitl7.t?n AGENT❑ <br /> If*ill'Pl.&'ANl'is not Me 1111.1.1NG P.ILZ1 proof of authorization to sign is required Title <br /> r\lJ'I'IIORIZA-I'ION '1'0 R1:LEASE INF012MA'11ON: When applicable, 1, the owner or operator of the property located at the• <br /> :ibuve site address, hereby authorize [lie release ol' any and all results, geotechnical data and/or environmental/site assessmcm <br /> information to the SAN JOAQUIN COUN'T'Y ENVIRONMI:N'I'Al.1iGAl;l'tl DEI'ARTMGN'r as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: (-b v <br /> l <br /> CDldMENT$: MAR 2 9 ZOOS <br /> i <br /> SAN JOAQUIN COUNTY <br /> i ENVIRONMENTAL ' <br /> HEALTH DEPARTMENT <br /> i <br /> APPROVED BY: �•r' t EMPLOYEE#: 3 / DATE: � v� <br /> VV—• l ti <br /> ASSIGNED T0: V-Z I/ /.s ! EMPLOYEE I: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ? g <br /> I Fee Amount: Amount Paid Z �� (� Payment Date J <br /> I Z� (� <br /> Payment Type Invoice # Check $1 Received By: <br /> EHO 48-01.025 SERVICE REQUEST FUR <br /> =";SED 6-5-02 <br />