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UZI L7f LYWO - 10:3f , ZVJ4003433 r I In rLwr[ rriva_ cis <br /> 0 1\JUAVU111Y tuJ.N L Y 1!,1N ViKUNMJ:NTAL "VALTH D "4RTMENT . <br /> SERVICE REQUEST <br /> s ype of Business or Property FACILITY ID II SERVICE REQUEST# <br /> �/1 ! Ni I, 1�1 i4P�i �� OdQ�(F7% ��00•�-�� <br /> OWNER I OPERATOR CHECK if BILLING ADDREs3❑ <br /> FACIt rTY NAME CAL 1'F(9 (`NIA <br /> SIrE ADDRESS 2 Z <br /> M A 'J l "c rZc� S c gra N' qu os <br /> Street Number Dfreefion Street Na CI Zi ;ode <br /> HOME Or IIAAILurG ADDRESS (If Different frwn Site Address) <br /> Street Number Sh.erlNam <br /> CITY STATE ZIP <br /> PHONE 81 EXT. AP14 III LAND USE APPLNCATION 0 <br /> ( 1 <br /> PHONEli1 ExT• BOS DISTRICT LOCATION CODE <br /> i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �j <br /> CHECK if BILLING ADORESS�^ <br /> BUSINESS NAMEA PHONE# E-XT. <br /> HOME Or MAILING ADDRESS FAx# <br /> (3(),T--TT- 33 2 o— C ( <br /> CITY C 0 t1 /1 P—A STATE C A ZIP q ? O <br /> BILLING ACKNOWLEDGEMENT! I, the undersigned property or business owner, operator or authorized .agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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,,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 2y� boal-- DATE:PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT CO M!'L 1 AAI Cr-- <br /> 1f APFL1CANT iS not the BILLING PARTY proof of autlforitatioN to sign is required Th l e <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 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 SERVtcE REQUESTED; r P4A L E A t L I i-J Cr • gE-z <br /> CorltwsrrtS: L,,S "]— 4-.� % J F—(T REE <br /> � 1 2005 <br /> 'SAN OAQQUIN COUNTY <br /> ACCEPTED BY: �� EMPLOYEE fit: <br /> F�01 L / �� C 3 2-' E J <br /> ASSIGNED TO: C L� f 1 EMPLOYEE#: —7_�S g-�) DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f��i PIE: <br /> Fee Amount: ��a �, Amount Paid Payment Date <br /> Payment Type lnvace# Check# Received By: <br /> END 025 <br /> REVISED <br /> B€D 1 S 1f1712003 <br /> ENVIR01<k!"EN T I-IFALTH <br /> PEI1PMIT/SF.9VICES <br />