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SAN JOAQUIN Ccoy�NYT�GI-!NMNTI i,HBALTH DEPA A <br /> Yil�ii <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY 1D# SERVICE REQUEST 6 <br /> C-tIks : . S-rA; 6I`J FA 0063717 52004g307- <br /> OWNER 1 OPERATOR ©� dHWK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSi <br /> 43e� �l ZI <br /> street Number trectlon Sire <br /> HOME or MAIUtlG ADDRESS {14 Different from site Address) <br /> street Number Street Na a 4 <br /> Gm' STATE ZIP <br /> PNONEtt1 Ely' --JAPN# LAND USE APPLICATION t a. <br /> PHONE#Z EXT ao$DISTRICT LOCATION CODs' <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> rEQUESTOR t 1 <br /> /o „. i f_P` t CNEGKif BILLING ADDREss BUSNESS NAMEPF3cT <br /> Ho 61 �.t3— X63 <br /> }TONE or MAIUNG ADDRESS ' <br /> CITY - ®� STATE ZIP <br /> C 1 , <br /> BILLING ACIiN{]WLEDGEl41P.i�iT: I,the undersigicd property or business owner,operator or authorized agent of same, `} <br /> acknowledge that all site and/or project Specific fiNV11tONtv11;NI',AL HEALTH DEpART�aNT hourly charges assoeiatCCl with this project <br /> or activity will be billed to me or my business as identified ort this form. <br /> I also certify that I have prepared this application and that the wgrk to be performed will be done in accordance with all SAN JOAQUIN <br /> CouxTY OrdiIu4nee Codes,Standards,STATE and FEDBRAL laws. <br /> + �; tt til ' DATE: it, I/ J <br /> APPLICANT'S SIGNATTTRE: .1 <br /> PRo.wTy I BUSINESS OWNER❑ OPERATOR I MANAGER� O�A AUTHORIZEID Ac>rPT�� <br /> If,APparc1Nr is not the Bl7.rtTtc P 2R7 f'.proof of authoritatiah to sin is require+t 'Title <br /> AEJ gW)LIZATION TO MIXASE IfORMATtON: When applicable,I,the;owner or operator of the property located at the <br /> above site address,hereby authorize the release of any and all results geotechnical data and/or environX>vtientaUsite assessment ; <br /> information to the SAN JOAQUIN COUNTY ENVIRONtviE?]TAL H>vALTII DEpARTMSNr as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE RE4Uww. U S T .12&-20�/ T - <br /> coMNEtIT3: 11wu.---}�• i�s- e U' -E" Vii -�uuaue�fib° isfc <br /> AGCEP=BY: 2. EMPLOYEE#: 0 3 Z 1 DATE: (O /Z/cs <br /> ASSIGNED To: a EMPLOYEE#: 3 DATE: <br /> Date Service.Completed (If already completed): SERVICE CODE. / g P t E' 2 3 O O <br /> Fee Amount ...176j;Q0 Amount Paid �g. Payment Dace 10 /2.1Q$ <br /> Payment Type /% Invoice# Check# (� 78,2. Received By: N <br /> PAWOW`t(Golden Rod) <br /> REVISED <br /> 111 s .. RECEIVE® <br /> REVISED 4111712003 <br /> OCT 12 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />