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SAN JOAQUIN C01JNTV ENVIRONMENTAL HEALTH DEKA irrmENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ib 0 SERVICE REQUEST# <br /> OWNER/OpgRATOR CHECK <br /> FAciuTY NAME 22-A <br /> SITE ADDRESS .7-146 <br /> < <br /> $itV}bt Naartlaf Giro antttvt Namw t GI Cada <br /> or MAILING ADDRESS (it Different from Site Address) Stmot Number straut Niumv <br /> CITY STATE zip <br /> PHDNE#i Ext'- APN# LAND USE APPLICATIDN 0 <br /> cuoq 576 � <br /> PHONE#2 r;KT. 1308 Disypticy LOCA-noN coag <br /> coN,rRACTOR SERVICE REQUESTOR <br /> REQUESTOR if.1/2 41 e-A A/- CNECKII'&J, INGADDRE&D <br /> OUSINESS NAME PNONE# Ex, <br /> 40;e- 72 -20d—1 " <br /> HOME Or MAILING AD DrRESSrAx# <br /> 2 ,149"-*2 -r-V4 (idh 3 9�- <br /> CITY e—J,S`e-0 SYAY15 C 4. ZIP C7 el'I <br /> HILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator Or authorized agent of Same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 1311-11AItTMENT hourly charges associated with this project <br /> or activity will be billed to rue or my business as identified an this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in twcordance with all SAN JOAQUIN <br /> COUNTY Ordhwncv(.(gks,,%andards,,S-rATE and FF.l)1-.'1ZAl..laws. <br /> APPLICANTISS(GNATURE: I)A7fh:: <br /> PROPERTY/BLISMss OWNER 0 OrEaA-roiz/MANAGE'll M <br /> ?f,4PPLt(,4iv7,is-not the B1L1,1A1G'1',,ixTY,pr(mf of elUehorization to sign is required/ Vritle <br /> AVI'HORIZATION 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 tile SAN JOAQUIN COUNTY ENVIRONMENTAL,Hr7m;ri-i DiLPAIZI-MENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERvicE Rmumm), <br /> COMUNTS: <br /> AcCEPTE11 BY: Empt-oYFE DATC: <br /> ASSIGNED To: EMPLOYEE DATE: <br /> Date Service Completed (If already rompleted), SERVICE COOS: <br /> Fee Amount: Amount Paid payment Date <br /> Payment Type Invoice Check# Received By: <br /> EHO 0-02-026 rpR FORM(GoIdurt Rod) <br /> REVISED 11/17/2003 <br /> IT/Z0 39Vd 1-1IH AonHO CZ9666ET99 90:1T 600Z0100 <br />