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Sep 2,,8 04 11:48a <br />H R E W, <br />neering <br />8188423 <br />0 <br />i <br />v i%•i v.r#1'rIAN JOAQUIN, IUOUNTYENVIRONMENTA•WAUA TM'llEPARTMENF <br />SERVICE REQUEST <br />Type of Business or Property <br />. , FACILITY ID M <br />SERVICE REQUEST If <br />/ <br />)Ery <br />p <br />$rxt <br />OWNER I OPERATOR <br />g�u,rlc AoonEss❑ <br />,--j /GPMA,"— , <br />FAz1 <br />(OR) <br />FAtWfs NAYS <br />CRY -F-� l.(( �i�.l(.C- <br />SITE ADDRESS.�.Tp,p <br />Zip ci 6'L <br />1�3 1:. IlrH ST-. <br />Date Service Completed (K akea*emplatoo.. <br />15,b M. lI rst,ee W <br />i <br />Fee Anwunl: <br />sr.edw <br />Payment Type <br />z aa. <br />HOPE or M ALEGADDRESS (tf Different from Site Address) <br />Chock B 1'1 r�3 Recelvoa By <br />6gr W . 3fd Sl . <br />r <br />N.m <br />H rb� <br />S'Gr. - R323a <br />ptwtEHF"*• MN• <br />LANo UsTAPPuuATIDNY <br />16911 91 3, - -7,2. IS- <br />PMORe1j res,. <br />BOS DeTR1eT <br />LVr AsroN COM <br />( 5 ) 583 - 3'L3 S <br />CONTRACTOR / SERVICE-REQUESTOR <br />REQUESTOR A ,IMM �1 Inr�c-17 i / jt I <br />/ori r'U rf <br />^r-,Q_p FrT <br />c+recur1,t«c aoonEss <br />\ �j� <br />BUsmEsa NAME l�. U Mo <br />!� <br />\ <br />p <br />$rxt <br />�•.. <br />��z_36yU <br />Harr w fiWma ADDRESSLPM�-Q P' LO <br />2o-1 W P 3 <br />EawtoveE#: 03p 2p-.(� <br />FAz1 <br />(OR) <br />842- -?-16 o <br />CRY -F-� l.(( �i�.l(.C- <br />STATE�+�. <br />Zip ci 6'L <br />BILLING ACKNOWI.EDGEMENT: I, the underugued property or business owner, opentor or authored agent of same, <br />aclaowledgc that all site aodlor project spccific ENvIRONmENTAL HEALTH DiNARTmItNT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this foruL <br />I also certify that I have prWued this application and work to be performed will be done in accordance wish all SAN JOAQUIN <br />COUNTY Ordinance Codes, Srandards, STATE d laws. <br />Y APPLICANT'S SIGNA917R8: DATE: <br />Pa0r"Tv1Busurrss OwMM11 �Oft"WR I M.Trucaa ❑ OTHMAUTHORrseo AGEr rQ� <br />/jMPLrwA7isnolth.&U"GPAxm. proof ofaadrorizadontosigeUrequired rid, <br />AtrrHORIZATION TO RELEASE INFORMATION: When applicable, L the owner or operator of the property located at the <br />above site address, hereby authorize thoU.r.e.�lease of any and all results, geotechnical data aallor eaviroomcutallsite assessment <br />informEN• <br />information to the SAN TOAQUiN COUNTY HtONMBNTAL HEALTH DEPARTMENT w soon as it b aviil&415 and.a�fhq same lima it 6 <br />provided to me or my repro tntativo. iii I r i J. i <br />TYPE OF SLRYF.ERUMESTED: r" -r <br />^r-,Q_p FrT <br />C0W1 <br />SEP 2 9 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />AccmTmBr. <br />pLttJEtt�A <br />EawtoveE#: 03p 2p-.(� <br />DATE: 9 2Y fir. <br />ASSIGNEoro: <br />S l <br />EwPLorEE#: ] e r/ <br />DArEi I 2q EJ <br />Date Service Completed (K akea*emplatoo.. <br />SMrECOM 'fGQ' <br />PIE: aT_CS <br />Fee Anwunl: <br />�� Cr , O� Amount Pald Z, - Payment Date p <br />R act y <br />Payment Type <br />✓ Involve <br />Chock B 1'1 r�3 Recelvoa By <br />EHD 4"2.025 <br />REVISED W11120M <br />Z0 39vd H1T73H 1V-N3WMdIPJ43 <br />SR FORM (Gilden Rod) <br />8EI0179b r5:68 1,00Z/bZ/60 <br />