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OWNER! OPERATOR <br />Direction Street Number <br />514-iv ' <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />." <br />CITY <br />ZIP STATE <br />FACILITY ID # <br />PA-0003/0 <br />SERVICE REQUEST # <br />Se t 0 12-2—i ( <br />Type of Business or Property <br />FACILITY NAME <br />SITEADDRE S <br />C>) <br />4-cvc/ T7 g4c_. <br />-rzie;Gme 13co <br />7.-‘2.1+ <br />City 1 Zip Code <br />Street Number Street Name <br />PHONE #1 <br />) <br />PHONE #2 <br />EXT. <br />g 6 Do o <br />EXT. <br />II <br />LOCATION CODE <br />APN # LAND USE APPLICATION # <br />BOS DISTRICT <br />CHECK if BILLING ADDRESS El <br />APPLICANT'S SIGNATURE: — <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> DATE: <br />PEFtATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />rz5-: 3 <br />"-- <br />PROPERTY / BUSINESS OWNER!: <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST91 <br />6-6 /2--ta-f7-5 ‘— <br />HOME or MAILING ADDRESS <br />T.16 C4-5-17 <br /> 1___4) <br />FAX # <br />S Tt il ZIP 47 <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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or 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 and FEDERAL 1 <br />BUSINESS N PHONE # EXT . <br />(9C51 ) <br />pCHECK if BILLING ADDR _) <br />proviueu to we U1 lily , <br />TYPE OF SERVICE REQUESTED: <br />7 r <br />l <br /> <br />-.am. <br />COMMENTS: <br />ww, <br />MAY - 62O05 <br />sANJ°AQuiN co ,,NvilioNmEN..p. Nry <br />ritALTH DEpAR.rmEL r <br />ACCEPTED BY: EMPLOYEE #: 9K7 y 9 DATE: <br />_-- ----- <br />ASSIGNED TO. yi,(-k '/1,--,,-. EMPLOYEE #: / (r) (77 DATE: <br />Date Service' ompleted ( <br /> 2 <br />Iready mpleted): SERVICE CODE.: C Cci PIE: <br />Amount Paid r 3 _-Payment Date <br />Fee Amount: 1)) <br />Payment Type Invoice # Check #i - b k e/ I ceiv d By:Xe <br />SR FORM (Golden Rod) <br />El-ID 48-02-025 <br />REVISED 11/17/2003