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VJOW <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT" <br /> SERVICE, REQUEST i <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> 0_11--i 0", C �. Cr�rCx tf t3itLlNri ADDREss <br /> FACILITY NAMEty � <br /> SITE ADDRESS" I�1� �� J <br /> L V 1 u� Number Oirrdlan t� !r- ; <br /> . Zio Code <br /> ROME or IM1A1LiNG ADDRESS (If Different from Site Address) <br /> stmtstmet Numbyr sifftfil NAM <br /> CITY STATE zip <br /> i5 <br /> PHONE#1 APN>f LAND USE APPLICATION# <br /> (am) q6"9 - S <br /> PHONE 12 r -� ��— T• FS DISTRICT <br /> LOCATION CODE <br /> + ) ?•-'S <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> E{]UESTOR CHECK it t fUuNG ADORE$ffiL. <br /> WL !S <br /> SustNEss NAME C` PHOXE# Ex � <br /> HOME or MAILING AO KESS FAX# <br /> CiTyIPl,1`. k �i'..�_41. 4 TATE <br /> BILII,ING ACKNOW1,EDGEME'NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAt.Tn L`7F.PARTMEXT IMurly charges associated with this project or <br /> activity will be billed to rue or my business as identified on this form. <br /> I also certify that l have prepared this application and that the work to be performed will be drone in accordance-with all SAN JOAQUIN <br /> C()UNTY Ordinance Cortes,Standards,STATE andia-m-•RALlaws. �} 1110 <br /> APPLICANT'S SIGNATURE: AR�jII4.r - _3 DATE: cam- n <br /> YPROPERTY/Tit:CINFSS OWNEIS❑ OPEUATOR t MANAGER 0 OTItFR AtmiciRizvo ACENT� I, L *j� <br /> If APPLtC:,t N7"is not the Biy tN proof n,f authorization to sign it required Tide <br /> ALITHOR17.ATION 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 environmental1site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAt,Ti,i DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PAYMENT <br /> TYPE oF SERVICE REJQi1ESTED: t �t ru t yr—�. <br /> C{)M1iENTS: <br /> TUG ' 9AM) <br /> ow" SAN JOAQUIN Co uNTY <br /> PU&ICHEALTH SERVICES <br /> � ED&LIArMf Ai HEALTH Divisft <br /> APPROVED 8Y: rr�/t�5 EMPLOYEE III: C,> DATE:`' <br /> ASSIGNED TO: i !'G ' EMPLOYEE#: `�>; Z:. DATE"!5r. '.�7 <br /> Date Service Completed (if already eompieted): SERVICE CODE: ' r P 1 E: '. <br /> Fee Amount: . j Amount Paid Payment Date <br /> Payment Type invoice# Check#1 Received By: <br /> EHO 48-01-025p��� r SERVICE REQUEST FORM <br /> REVISEO s-"2 7 p <br />