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08/7,9/2002 <br />12:45 4640AkUNTY <br />ENVIRONMENTAL LTH <br />6A.NJ0AQ1EINVROINMEN7AI,kix;A�;�I EFA.KE.MLN'r <br />SERVICE' QUEST <br />PAGE , 01 <br />• P <br />Type of Business or Property <br />BusiNEss NAMz <br />FA L TY ID'# <br />HOME or MAILING ADDRESS <br />asaa(et <br />SERVICE REQUEST # ' .. '.. <br />CITY (�>Ur C STATE ® t <br />OWNER / OPERATOR <br />0 <br />' <br />CNECKif BILUNQ n €s <br />FACiurY NAME <br />SITE ADDRESSO� <br />n <br />\le— <br />�a <br />StYaat NumbAr <br />Dlrectton <br />C.Jv <br />N�� <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street N�rmber§jrt2j <br />Ngmg <br />CITY <br />STATE ZIP <br />PH0NE#1 E'R'APN <br />( ) <br />LAND USE APPLICA11ON <br />PHQNE #2 Ezr. <br />{)15fRiCT'''"' ocaTitibti F' <br />$C1$ LN'C <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR CHECK if BILUN4ZAr1QRF1&-q13 <br />BusiNEss NAMz <br />PHONE# Exr. <br />HOME or MAILING ADDRESS <br />asaa(et <br />FAx # <br />CITY (�>Ur C STATE ® t <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 ENviROMvrENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to tate 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, S TS and FERE WS. <br />APPLICANT'S SZGNAxiIRE: DATE: / / <br />PROPER'rYIJaUSINe$5 OWNEAIJ OPERATOR/ MANAGER ❑ OT AUTUORIZEnAGE <br />if APPLICANT is not the RTY proof of authorization to sign is requirek Title <br />A7 Z'U!QN TO RELEASE INFO TION: When applicable, Y, 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 JOAQUN 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 />I TYPE OF 8mcc REQUESTED: ' ( ) �,' T r e t rO . f ( I <br />COMMENTS: <br />,APPRov zO BY:.. -- <br />IGNED TO'" <br />t3ate Service Complete (If already comp!®ted): <br />DeeAmount:. 7 ' j Amount Paid <br />Payment Type Invoice # <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />DATE:. <br />EMP>"oYFe �:: 2:. 'L <br />EMPLOYEE i C ., ::I' •. <br />'DATE'.,.:":. i1.; <br />SFatvlcE CobE: P f E: <br />Payment bate <br />Check # :.. Recaivgd By. .. <br />SERVICE REQUESTifORM <br />