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11/20/2002 17:55 2094671118 AGE STOCKTON PAGE 01/01 <br /> 11/20/2002 16:55 464Er ENVIRONMENTAL F TH PAGE 01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID a VICE REOUES_"t'4 <br /> T01\71 3► q J' <br /> OWNER/OPERATOR CxEpc 11 BILLING AOORse4❑ <br /> E <br /> FAciuryflAME <br /> SITE AD 01111811 f . q a s�,u IL t YU <br /> � D <br /> Home or MAILING Writes (it Different frpm site Address) <br /> Z 3 rM"Nuffiliar <br /> CITY 9T ZIP <br /> D <br /> PxonEAl FXT. APN f Lbm Oei AppwcArIom/ <br /> ( V) <br /> PHONE I@ Exr. DOS Onn,CT LOCATON CAOa <br /> CONTRAC'T'OR/SERVICE REQUESTOR <br /> REQUESTOR ` CHECclr BOANA AaN7944❑ <br /> SJR V1 <br /> Buswess NAAtt: s Ear. <br /> IrAI.Grw Ax <br /> HOME or LAA ING ADDRESS FAX <br /> ( ) <br /> CITY LI)Lv.-rO4. <br /> STATE Cyt, LP <br /> B11,LIN Y ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTR DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to roe or my business as identified on this form. <br /> I also certify that I have prepared tide application and that the work[o be performed will be done in accordance with all SAN 10AQUIN <br /> COUNTY Ordinance Codeu,Standards,ST 'rE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: tel' �G� 1,4A (41WfLL DAT, <br /> E:( Il �Z <br /> PROPERTYITIUStNEssOWNER❑ OPSRATOR/MANAGER ❑ OnreaAUTHOBIz®Acrsrrr4l <br /> If APPLICANT is not the BANG PAmz proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA,SR INFORMATION: When applicable,X,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 AntUor environmental/site assessment <br /> information to the SAN YOAQUW COUHTy ENVIRONMENTAL HEALTIi DBPARTMBNr na soon as It 1s available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REOUEMD: <br /> COMNENIS: ♦ , <br /> APPnGVLV aY: EMPLOYEE1k 27., CZ- <br /> ASSIGNED TO: 1IMPLOVEB A: a 3 8 DATE: <br /> Date Service Completed (If alroodyawidified): SE1MCEfiM 1) 3 PIE: -LJ O It <br /> Fee Amount: .(Db.o �Q Amount Paid Payment DntB - -. <br /> Payment Type Intrpiea M Check k n Reeo RVI ets `_, L. E[D) <br /> EFi048-0102�, SE I�j02 <br />