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SAN JOAQUIN oww ENVIRONMENTAL HEALTH DEP <br /> SERVICE REQUEST <br /> Type of Business or Pmperty FACILITY ID# =REQUEST# <br /> GAS 5TkTC6C� FA 001361 52oo gA313 <br /> OWNER/OPERATOR `` 7 - <br /> C'r7�,1`Otl CHECK if BILLING ADDRESSC7 <br /> FAuuTY NAME <br /> SITE ADDRESS - <br /> 14 4 StreHTlumbpr rcQien etre e E 21 Caa <br /> HOME or MAILING ADDRESS pf Different from Site Address) <br /> Street Number Street Ne a <br /> CITY STATE ZIP <br /> PHONE#tT• APN# LAND USE APPLICATION# <br /> taoq) �g9 , o1�•q <br /> PHONE#2 ET• ROS DISTRICT LOCATION COLE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RE4UESTORs. <br /> �1/p��� CJHECNif RII.uNO ApDDREss® <br /> BUSINESS NAME�`e__Ul - J�I(.DN ki'✓c J,. ui P�-(L � al3 � 0 CR. <br /> HON¢ r WNG ADDRESS Ylhl FAX <br /> �Y ii ,re.. (.M?) -&0c)*^ <br /> "TY O-6& J os pSTATE CJ4 ZIP 9611 <br /> O— <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 ENVERONMBNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business asidentified on this form. <br /> T also certify that I have prepared this application and(hat the work to be performed will be done in accordance With all SAAB JOAQUIN <br /> COUNTY Ordtnonee Codes,Stmtdards,STATE and FEDERAL laws. 1 / <br /> APPLICANT'S SIGNATURE: 4 �&o �.V � DATE: I610-W`AP���� �,t� <br /> PROUMTY/Busrflus OWNUCI OPERATOR/MANAGER OTrrM. AUTHoEEZB.o AGLN'r1% r6(4(�Lt"U &CklQictQ•bIr <br /> If ARPLICANrisnotfhe BizcrvcpA,? proof ofauthorization to sign is required rifle <br /> AUTHORIZATION TO REXXASE RTORMATION: When applicable,I,tho owner or operator of the property located at the <br /> above site address,hereby authorize the release of any and all rosults, geotechnical data and/or cnvironmental/she assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONhIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me of my representative. <br /> TYPE OF SERVICE REQUESTED: UST .1eZ77W C17- <br /> COMNEHTa: SSS U.)to pe. I,t4.3�t.C. GLet, c(_ <br /> ►1titrUilorr sociu1Q lgu�ecle ►nay bt✓ ve�ui�e� , J <br /> ACCEPTED'BY: ©L-LULLlP-,¢ EMPLOYEE#: 03.2. 1 DATE: IO m 05 <br /> Assiameo Tp. EMPLOYEE#: . 3 DATE: 10/12_/05 " <br /> p e. <br /> Date Service Ctimpleted (!f already complete SERNCE CODE: I _(Sri PIE: 2_3 OP <br /> Fee Amount 00 AmountPald Payment Date 3' <br /> - 279. � , oo (o t2/o5 <br /> Payment Type , .V Invoice# Check# [179 Q Received By: pJ <br /> EHD 48.02.025 RECEIVEQFORM(Golden Rod, <br /> REVISED 1111712003 <br /> OCT 12.2005 <br /> SAN JOAQUI14 COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />