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08/19/2002 12:45 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> 6A.N J OAQUIN NTY J✓+NVIR01 JWEAL UEA.J;J'JJ 1A1k1WCMNT <br /> ERV REQUEST <br /> Type of Business or Property FACILITY ID'# SERVICE REQUEST <br /> Qs- <br /> OWNER/OPERATOR <br /> ' CHECK if BILLtNt?ADDRESS <br /> FAci rrY NAME <br /> �7U-\ _ <br /> SITE ADDRESS /9,7� _ 1S�p�O/ <br /> stmof Numder Direction NarncQbt <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Numb., <br /> CITY STATE ZIP <br /> PHONE#1 PXT• APN# LAND UsE APPLICATION# <br /> ca - gg <br /> PHoN>;#2 FXT f30$'D,tSTrttcz� �>'; 'i'�`.; �- OTM C'bd <br /> '�,i�3q;7,.e.,sr�•+-•��W?S1;o,F:s«�:.:~'= 'na• riSk� "'G' t <br /> ( ) <br /> CONTRACTOR SERr16E REQLec"_:•'°it=aGRORr3i°. •�.. >...,;� _ •_)':.;�T.sr 4•x.2.r�=• <br /> P RQUESTOR CHECK If BILLING ADDRESS <br /> •1-.c�rr'a.. R2 SEr�- <br /> 8 susiNEss NAME -- o,� # EXT <br /> i 1r1 v t g" 0 - %Z <br /> HOMEOr AILI S FAX# <br /> CITY ESTATE C� ZIP �jAlO-y <br /> BILLING ACItNO DGE NT: I, the'uudersigned property or business owner, operator or authorized agent of same,. <br /> acknowledge that all site and/or project specific ENviRoNmENTALHEALTH DEPARTMENT hourly charges associated with this projector . . <br /> activity will be billed to we or my business as identified on this fortri <br /> I 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 /> COUNTY Ordinance Codes,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 9119110 <br /> PROPERTY/)3usiNesS Ovmzri❑ OPERATOR/MANAGER ❑ 14mA.uTIhORIZEnAGENT <br /> IfAPPL .4NTis not theA&Mdq,-ARTY,proof of authorization to sign is require Title <br /> AUTRORIZATMI TO RELEASE)<NIF'OIt)utA'IION:When applicable,T,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 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: ' <br /> COMMErrrs: <br /> APPROYEAgy;. ._. . ....__ '. EIbPLOYtre>#• • ' DATE: <br /> ' <br /> "EDTO:. EMPL DY!H#` >:" Tri;:;•, '',- <br /> bateService'Comptatt3d (lfeireadycorlrplet®d}: $ Cosi ; PfE: <br /> eQ Amount:•. ,: Amaunt Paid <br /> Payment Date <br /> Payment Type. Invoice# `• check#' _•: '' _ ad Br <br /> e 's <br /> �•a <br /> sEHD 484i-025CE <br /> REMSED 6 6 02 t� , <br />