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09I0112004 16:23 2894683433 <br /> FIFIH I-Luur< <br /> a A''I J UAQIJ 1 r♦ "WN 1".y r N V IRON HENT A-L JAEAL`I'H 1)E-4,RTMENT <br /> SERVICE REQUEST <br /> Type aF Wiliness or Property FACILITY ID I« SERVICE REQUEST g <br /> ,4CT,4 IC �r b IJ. } s(� C) o S z <br /> OWNER/OPERATOR CHECK it BILLING AnnprSS❑ <br /> FACIL ry NAME / /�,y <br /> $ITE(ADDRESS c / ��/`J`� L IO1IE + � --Tr l C `I y��9 <br /> L. "� 9k�::Number Dirve[Wlon &nret Name C 21 Code <br /> HOME of MAjuNG ADDRESS (if Different front Site Address) <br /> ESweet Taurnbt r rest Name <br /> �m STATE ZIP <br /> PHONE EIAPN# LAND Us[ APPLICATION# <br /> (W1 <br /> PHONE02 * BOS DISTRICT LOcAnONCODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR r O( ( � C►tEC+c if BILLING-ADDRE",t�0 <br /> BuSIN>iss NAMEPHONE k <br /> LL7C�C 532 -73 2 <br /> Mow or MAL NtIG ADDRESS FAK I <br /> CITY < STATE CA t ZIP of,s ^7 0 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> aCknow'ledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> activity will be billed to me or my business as identified on this form, <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance With all SAN JOA01nN <br /> COUNTY C)rdineace Cortes,Standards, STA10E anj FFD' <br /> L laws, <br /> APPLICANT'S SIGNATURE: i5L DATE: f G <br /> PROPERTY/SGSINESs OWNER❑ OPERATOR/MANAGER © OTHER AVTH0RIZED AGENT is —Y <br /> If,APPIfGlNT is not the BILLING PA,I! proof ofauthorization to sign is rega►ired TWe <br /> AiMHOPUZATION TO gELEASE 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, Reotechnical data and/or environmental/site assessrn <br /> information to the SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPARTrifNT as soon as it is available and at the s04� rr-, <br /> provided to me or my representative. <br /> TYPE OF SERVICE REWESTED: LCI� <br /> �yN <br /> - <br /> C1v1N N�A�" S <br /> � rC-- l VL/C v n .SE'n.1 S C�2 r AJT�4�t1 k / SPS,�© o -10'EN <br /> ACCEPTED BY: ULt U Et t A EMPLOYEE N: C)2 �r DANE <br /> ASSIGNED TO: I l' EMPLOYEE/F' ' 3,�>U DATE f 11 <br /> Date Service Completed (if already completed): SERVICE CODEcj P 1 Z <br /> : <br /> fee Amourd. - 2--, 1q, cAD Amount Paid 16 -1-7 f- LrD Payrrterlt Date q �l d y <br /> Payment Type invoice# Check B -7-7' 2-- Recaivod By, <br /> EHD 4M2-1125 SR FORM(Gafden Rot!) <br /> REVISED 11I17l2003 <br />