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07/30/2008 WED 15: 21 FAX 2094683433 SJC EHD ZOC-11030 <br /> SAN 3 OAQAhm COIJNTY ENVIRONMENTAL HEAT '17 `PAl!t NIL' NT <br /> SERVICE REQUEST qW <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> i <br /> O 'NER/OPERA OR <br /> CHECK If BiLLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS r ;. 01 � <br /> <" !f Sdreot Numt:er Direcfior, "�i � re® a �O t ' 2i code <br /> HOME or MAILING ADDRESS tf,Different from Site�Address) <br /> 2 f. i t`- , /(A StreetNumtter Street Name <br /> CITY STATE ZtP <br /> /. <br /> PHONE#1 Ex' AFN# LANG°U3E APPLICATION# <br /> PHONE#2 Ext. I BOS DISTRICT �i LOCATION CODE <br /> CONTRACTOR/ SERVICE RE,QUESTOR <br /> REQU TOR <br /> CHECK IfL 1-71 ILL�[�CyAD0RES5 <br /> 3 L ��� <br /> } �.' P040 <br /> BU,,StNESS NAME .� T r <br /> H?mg Of MAILINr ADDRES5 _ FAX# ` <br /> CITY ; STATE,,/ ZIP i�C •.) <br /> i <br /> BILLING WL M EMENT: 1, the undersigned property or business own-x, operator o: authorized agent of same, <br /> ac c iowledge that all site andlor project specif.c E'`VIROV>e4-;VT�.s.,HE�.�1'i,r DEMO Nim,4,howl,c':aarses associated with#Ivs projector <br /> activity will be billed to me or my Business as ideraitiyd on this form. <br /> I also certify that'T have prepared this application.:nd that the work to be performed will be done in accordanzze with all SAN JOAQUIN <br /> COUN7 Y Ordinance Codev,Standards,STAT;and FEDI-RAL laws. <br /> rl — <br /> APPLICANT'S SIGNATLIRE: „4i _„� ' �:.y <br /> PitoPEnTY/BUSINESSOWNER13 OPERATOR/$1ANAGFfR � OTI?[RAt3�hcutlzenAvG�Z i� <br /> If.4miucANT is nor the B/utnG Prr,TI;Proof of aur/rorizatlon to sign fs r equi?red 7'.rte <br /> AUTHORIZA'TION TO RELEASE INIZOICNIATION: When applicable; 1,the.owner Or operator of tlic property located at the <br /> above site address, Hereby authorize the release of any and all results, geotechnical data anTor enviteiunentai/site assessinent <br /> llif0rlT11tiOI1 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL ARTME NT as SDDiI l ll 15 available gild 1t the same time lE is <br /> provided to me o:my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> /C.> Il.S T"G+..•k'.f� YU,fE{`�.i.:lJ i=3C L_�.r"k._��� .tom .'`C.,; <br /> COMMENTS: d }/ ' <br /> SAN J()NUUiN COUNTY <br /> ENV!A(}t�ML0;AL <br /> ACCEPTED BY: EhiPLOYEE#: DATE: i <br /> ASSIGNED TO: EMPLOYEE e5602, DATE: <br /> Date Service Completed (if already completed : S1 .ERVICc"CCOE: . PIE:2, <br /> i Fee Amount: n" Amount Paid ,q ,1 ,l-r", Paym ni pate r : <br /> Ft Pay–merit Type Involve# Check# F a., b Received By. t. :. <br /> EHD 46-02-025 SR FORM(Golder,Rod) <br /> REVISED 11/17/2003 <br />