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SAN JOAQUIN COUNTY ENV TRONMEN T AL HEALTH DEPARTMENT <br /> SE+RVTCE REQUEST <br /> Typo of 9usinev;gr Property FACILITY Ib SERVICE RMINST C <br /> t7wNe -- <br /> � <br /> QAC:Im NAfdE �� _ f � <br /> SITE ADDarSS <br /> $h umber gkealle rar s r <br /> HumE or MAIL]Nn ADDRE$s (q'0;ftrenf rr0M SKe Addrns;s,) <br /> rimr er .. <br /> CITY STATI! <br /> PHowfil rlxr, APN LAW U21!APPLICATION f$ <br /> { <br /> P14ONE 42 Md. Bas dr9YRICP LerA�ora Cvua <br /> —" CONTRACTORERVICF. REQUESTOR <br /> i�eC1UEgT'dl� � - GHQ�P�J LINtA qRe= <br /> c� <br /> I.. <br /> Homa ar hsuNG A 8699 FAX r <br /> CITY STAtS Ali <br /> 13xLLTNC.A_ h?�'t7 bG I, the uridersignt:d property or bualaess owner, epe,rnior or PIX111wrixed agont of same, <br /> aclaWwledge that Itll site avdlor project spoof c$WROMMEhWAL I-NAO-F i OAKTMWT bouCy charges a ocictcd with two ptajecr x <br /> act(v(ty NOU be billed to the or uq hu0neSS as identified on this f6 m, <br /> Y also certify that 1 have prepared dais App tion and that tht w petformed WM be done in ace0fdAnCO with all SAN J0AQU� <br /> COLNTY OWburricc Codes,Strindards 1Arx) rr s. <br /> C APPLICANT'S SXGNA. M; <br /> PTtc)T MTY I8ti91rms O"VKF,R 4 EF! AWAG&I 0TmzR AuTH0R=n A(,6NT u <br /> If,ipPLICAAT is nor the prnnf df ararlrotiwrfarr tq sign is r'egrrlred rtrtc <br /> A�xz ,60011 MRMASE P&Q MA TION:When applicable, T, the owner or-oper$kar of the property lucatcd it the <br /> ai)ove site Addross, hereby authortze the ralease of any and all Tesuim, geotechnical data and/or enviroz�rnerrtalfRitr assessment <br /> informsdan to the SAM 10,kQUJN CDUlNn SN-W c0M .-NIT11,T,HFALTR DEPAN.TMBNT 45 aavn s&it as availpblC and at the anuric time it ra <br /> provided to roe or my rspmsenTudve, <br /> TrpE oasrpvlce RNUSSTE0: PA <br /> GBNMeNPtl: y <br /> AUG A 2 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> AccFem BY: EMPLOYEE P! DAM <br /> AssigNER Td: EMPLOYEF.M OATI <br /> Rath Serv(oe Complowd (It already c m'prtited): S€RME Coot_: If,E: <br /> Foo ARlaunt; Arnosunt Paid $ 31s 1-1 Z7 Payment 6ate 0 <br /> ` <br /> ' payment Typo . IrTvota v Check#1 Recelvod By. <br /> EH0 48•R2-M 913 FORM(GaIdon Rud) <br /> REVrsEO 111371?003 <br />