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X3110 ,r \r N%Z LjtlI %.VUI\ t 1 1'+I\ Y AL1\J1 ILYA I:11 1 ML, Il1G/1I, 1 1-41t-i\Ill 111.1 I,IY 1 <br />SERVICE REQUEs,r <br />1 <br />pe of Business or Property <br />FACILITY ID # <br />�� i 5 r) <br />SERVICE REQUEST # <br />s <br />C <br />IWNER / OPERATOR <br />`' 1 0 <br />MA i <br />CHECK if BILLING ADDRESS ❑ <br />F <br />CILITY NAME <br />ME Or NAILING ADDRESS <br />FAX# <br />S <br />E ADDRESS <br />/-ylo 9 <br />Street Number <br />Direction <br />Street Name <br />) \ STATE ZIP S Z1 , C> <br />--s*ocK Jun <br />CII <br />Zip Code <br />H <br />DME or MAILING ADDRESS (if Different from Site Address) <br />Slrcel Number <br />Slrcal Name <br />C <br />TY <br />STATE ZIP <br />PI <br />ONE #1 EXT. <br />SIGNED TO: <br />APN # <br />LAND USE APPLICATION <br />PI <br />ONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUEsTOR <br />R <br />-QUESTOR <br />CHECK If BILLING ADDRESS <br />El <br />JSINIESs NAME <br />NONE it Err. <br />`' 1 0 <br />MA i <br />H <br />ME Or NAILING ADDRESS <br />FAX# <br />Lo L <br />(20q) 3&S' 1,5`1,3 <br />C <br />) \ STATE ZIP S Z1 , C> <br />BILLING ACICNOWLEDGEMEN't': I, the undersigned property or business owner, operator or authorized agent: of Namc, <br />,iknowledge that all site and/or project specific ENVIRONMENTAL HEALTId DEPARTMENT hourly charges associated with this project;' <br />of activity will be billed to me or my business as identified on this lona. <br />I also certify that I have prepared this application and that the work to be petTormcd will be done in accordance with all SAN .It1A0u111: <br />COUNTY Ordinance C.'OclLs, Slurtck)rdl', STATE and FEDERAL laws. <br />A PLICANT'S SIGNATURE:! DATE: <br />PI ol`o-arrY I BusiNr•.ss OWNE.R❑ OPERATOR/ MANAGER ❑ OTllrlt AU'I'llolu .1) ACI:NT ❑ <br />I/'ill PLICINT iS nnl I/le BILLING PARTY, proof of aufhori afion to Sign is required Title <br />A THORIZA"I ION 'rO RELEASE INFORMATION: When applicable, 1, the owner or operator or Ilse property located at the <br />'itove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessrncnt <br />in brniation to the SAN JOApUIN COUNTY LNVIRONMENTAL I-IEALTIi DEPARTMENT as soon as it is available and al_ttv4-t,arne time it is <br />pr vided to me or my representative./I oA`iMEreI <br />T <br />PE OF SERVICE REQUESTED: �/ <br />RE <br />CC <br />MMENTS: <br />`' 1 0 <br />MA i <br />G00t' I <br />1N <br />SPN �� RONME�CMENT <br />H�,�TN HEPAR <br />Ac <br />CEPTED Y: <br />EMPLOYEE#: ` ( <br />DATE: <br />A <br />SIGNED TO: <br />EMPLOYEE#: <br />DATE:: <br />c <br />Date <br />Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 F: % J?�� <br />t= <br />a Amount: <br />Amount Paid <br />027 C� f] <br />Payment Date �o dG'S <br />f-'� <br />yment Type ✓ <br />invoice # <br />Check # <br />Received By: <br />EF D 48-02-025 <br />RE VISED 11/17/2003 <br />SR FORM (Golden Rod) <br />