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SAN JIDpQ ourrrY i Yv'Vtli nIfiN Al H'r+At I)1�,1>AIrrM • SERVICE REQUEST s Type el Business or Property FACILITY ID # QUEST OWNEC/ OPERATOR FI.Ci of NA �— V— ,-� <'F-, tx. t--, -A n- i S TE ADDRESS COMMENTS: � R - � E/�,�.v�►.�cyb,�,, � I b - l� of 'rte- may$ � ,- n a,d��-Sig--• —�J CHECK If BILLING ADDRES BUSINESS NAME — APPROVED BY: % EMPLOYEE #: /n 4 DATE. O PRONE # EXT. i cr �5— -r DATE: ---- street Number Direction 0 S r, Name i/ Cit Zi) Code COME or MAILING ADDRESS (If Different from Site Address) CIT_ –i Street Number Street Name CITY STATE ZIP ------- _I I PHONE 41 EXT. APN # LAND USE APPLICATION # l ) J PHONE 92 EXT. BOS DISTRICT 1 LOCATION COO[ i i CONTRACTOR / SERVICE REOUESTOR REQUESTOR COMMENTS: � R - � E/�,�.v�►.�cyb,�,, � I b - l� of 'rte- may$ � ,- n a,d��-Sig--• —�J CHECK If BILLING ADDRES BUSINESS NAME — APPROVED BY: % EMPLOYEE #: /n 4 DATE. O PRONE # EXT. i cr �5— -r DATE: ---- ME or MA TNG ADDRESS 0 FAx # o . # CIT_ STATt,144 zip B11,1 TNG ACICNOWI,EDGEMENT: I, the undersigned property or business owner, operator or aua thorized alert of sme; a:knowiedee that all site and/or project specific P.NVIRONMENTAI. I IFALTI I DHPAR"I'ML:NT hourly charges associated with this project or aztivity will be billed to nie or my busines as identified on this form. I also certify that I have prepay Ilii pp ication and that (lie wort: be performed will be done in accordan Jc�AUUIN COUN'T'Y Ordinuucc Cortes, Stcr9iiiigl. ,'$-I- ' t iA1 laws. t � APPLICANT'S SIGNATURk- DATE. "Z PROPERTY/ BUSINESS OWNER OPERATOR / MANAGER ❑ EIt AUTHORIZED AGENT ❑ 1 f APYI.ICANT is not 11re BILLING P,IItTY. I)roo authorization !o sign is regtrire�l Title AUTHORIZATION TO RELEASE, INFOR ON: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUI LINTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my rep ntative. TYPE OF SERVICE UESTED: U J PAYMENT COMMENTS: � R - � E/�,�.v�►.�cyb,�,, � I b - l� of 'rte- may$ � ,- n a,d��-Sig--• JUL 19 2005 SAN JOAQUIN COUNTY i ENVIRONMENTAL WEALTH DEPARTMENT — APPROVED BY: % EMPLOYEE #: /n 4 DATE. O ASSIGNED TO: G EMPLOYEE #: DATE: Uate Service Gompleted (if already completed): SERVICE CODE: (� PIE: ' Fee Amount: -7 q- DO Amount Paid �- Payment Date 0 j Payment TypeI>---Invoice # Check # k gog9' Re eived ey: �, " (� END 48-01-025SERVICE REQUEST FC RPA nr-;'16-5-02