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t <br /> SAN JOAQ ,1 COUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �a5ol ine Station 000 �. <br /> OWNER/OPERATOR p, 1� <br /> GNEvIZON F7r,(5 >UC.TS Co. CHECK If BILLING ADDRESS 1-3 <br /> FACILITY NAME*7-0- 1,74P1 <br /> SITEADDRESS 1103g, Ma-nficca <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> / SERVICE REQUESTOR <br /> REQUESTOR <br /> ya z &ian i n o , Proj• Mgr• CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> RHL DeSiagr) 6r4uP , Inc. _ _ 92s 313-41_lDiv._—II* <br /> HOME or MAILING ADDRESS FAX# a <br /> 1344 Arnold Drive A Suite Me.) 313 - 1?01 <br /> CITY martir»e STATE C.A► ZIP GI9'r,5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent o same <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with is project <br /> or activity will be billed to me or my business as identified on this form. <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,STATE'and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ �W�"'� M DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT RrMe4+ P <br /> IfAPPL1cANT is not the BmLiNGPAxTY,proof of authorization to sign is required d Title <br /> AUTHORIZATION TO RELEASE INFORMATION: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 environinental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and�t„"e time it is <br /> provided to me or my representative. QAY,v` <br /> TYPE OF SERVICE REQUESTED: Repair Ret TOT f t Plan GhaGk <br /> COMMENTS: pign c liee k for &pill containment fGPlacetncn�'. �ul <br /> GpUNN <br /> SAN JOIRONMewpa- ? <br /> NeLTN pEPARTM <br /> ACCEPTED BY: J i EMPLOYEE#: DATE: '-7 Z-710”-7 -I <br /> 0t�/ <br /> a <br /> ASSIGNED TO: a V UA (LA- EMPLOYEE#: ! '] DATE: -117,-7 10 <br /> / Z,'7 'O cl <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 2301 <br /> Fee Amount: 2 'l Gl , C" Amount Paid -7q , urD Payment Date -7 ;) ( O <br /> Payment Type Invoice# Check# go043!�— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />