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05=22-06 02:37Pm From-TAIT ENVIRO*L 714-560-8237 • T-666 P.02/06 F-995 <br /> SAN JOAQuN COUNTY EN'V'IRONMENTAL MULM DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY la# SERVICE REQUEST# <br /> 3OWNEAce, o' 3q �` se'oo +(Cr 19 ,3- <br /> OWNER <br /> R/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAzip end& <br /> ME <br /> SITE ADDRESS <br /> Stroot ar ',Ctlan StrantName CI <br /> ty <br /> HOME or MAILING ADDRESS (If Dlffarent from Site Address) <br /> StfBet Number Street Name <br /> CITY STATE zip <br /> PHONE#1 I=. APN 0 LAND USE APPUCATION <br /> ( ) <br /> PHONE#2 EXT. SO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> IZEQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> HOME or MAKING AnDRIESS FAX# <br /> ky'!+) <br /> CIN STATE ZIP <br /> 944& Z.4RAMJ70 / <br /> MLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagent of same, <br /> acknowledge that all site and/or project specific ENVIRONMLNTAL H-.ALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> f also cerrify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUN <br /> CouNTY Ordinance Codes,Standards,STATE and ERAL lawSp <br /> APPLICANT'S SIGNATURE: 'r DATE: � <br /> PROPERTY PRUSTNFSSOWNER�I OPERA'rOR MANACrFR Q OxrrenAuTadRt2MAGENTN i <br /> .1fAPPLJTCANT iS nor the Y31r.T-rNG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE MORMATION: When applicable, 1,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 environmenta"ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE'PARTMEN r as soon as it is available and' same time it is <br /> provided to me or my representative. �(M <br /> TYPE OF SERVICE REQUESTED: RE <br /> COMMENTS: P'� <br /> M N GCVN'N <br /> gAN SOP oNM� -1 <br /> HE,p`�(N O�PPP <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> As31GNE0TO: i C� EMPLOYEE#: t q3 I <br /> DATE: S 6 <br /> Date Service Completed (If Tread9completed): SERVICE CODE: Ct PIE' �8 <br /> Fee Amount: �� �� Amount Paid 'Sad�, 0.O Payment Date _5 �f 0 (a <br /> s <br /> Payment Type tl Invoice# Check# Received By: <br /> EH1348.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />