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08/19/2002. 12:45 4640138 ENVIRONMENTAL Hi TH PAGE 01 <br />:�iA.N JOAQUIN 41UN Y t1NVIXONMk:N',t'A.Lk1.EA.Ufkt FA.itT.D ENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 <br />'.FACILITY ID'# <br />SERVICE REQUEST # <br />% O a <br />V <br />ff V <br />1" O — <br />HOMEo M�i S <br />UQLA� B-10 <br />OWNER I OPERATOR <br />n n <br />CITY l3 <br />CHECK If BILLING ADDRES `1 <br />FACILITY NAME <br />1/0 <br />SITE ADDRESS <br />L�-f <br />Street Number <br />Direction <br />, <br />Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />CITY <br />ST'A'TE ZIP <br />PHONE#i <br />LAND USE APPLICATION# <br />( ) <br />7N# <br />F7HoNr; #2 <br />EXT. <br />$OS DISTRIC i _: - i°: ,:':' <br />,f, f•6- •5.ti _ `:�ri:•T�^r,. <br />..S.a:•:.'=...•:r.,-. 'f,,: <br />: LOCATIGN Cb <br />i.�k.C•'.��.. 4 <br />A. y+ <br />-'tsJ''iir:�•,r^.1.34';tk,i: <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />1 <br />CHECK If BILLING ADDMS&❑ <br />Busrtaess N ' <br />% O a <br />V <br />1" O — <br />HOMEo M�i S <br />UQLA� B-10 <br />FAX # <br />) 6 <br />CITY l3 <br />STATE ZIP <br />BILLING ACXNOWLEDGEMENT: I, the 'undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENviRONmENTAL I'IEALTH DEPARTMENT hourly charges associated with this project or <br />`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, ST Ts and FEDERAL laws ; ` <br />A,t'PL,CAl,IT'S S1iGNATURE: DATE: Z� <br />PROPSR,ry / ]BtisiNes OwNr,ta ❑ PERATOR / MANAGER ❑AUTiioRizEn AGENT -�M ` N 1 "-,Mg o— <br />IfAPPL1CANT is not theBlLGtN ,PART): proof of authorization to sign is require Witte <br />AUTHORIZATION TO RELEASE INF'ORMAT70N: 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAmi DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />COMMENTS: <br />EMPLQYEE#: ' DATE: '�•' <br />�As'SIGNEDT0:.' <br />pate Service 'Completad (If already completbd): S irlcr CobE: P! E: . <br />Fee Amount:• . - .' :., ount Pald Payment Date <br />Am <br />Payment Type `. Invoice # Check # Received By:' .. <br />EHD 4841-026 ` SERVICE REQUEI <br />REVISED 6-6-02 <br />