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.0110712010 18:43 1209?'1317 PAGE 01/02 <br /> ..'09/09/2009 MED 11:03 PAR 2096683433 S,7C Rep — Stockton Sery eta eq co 0002/OCA <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bushier or PMPNV FAM"-M a TSERVIC!REQUEST R <br /> 3ffii 1,5P <br /> OWN TOR <br /> L .NAM <br /> Cetrnd N <br /> FACNry-p <br /> HaRla.tuMAuIroAOOR56e prorneremtromsneAddr.us <br /> crtv STATe zip <br /> FNOaa H APN Y LAND Yee ARR.ioanON M <br /> PM01411 Ch. Boa chimer t.CCA CODE <br /> CONTRACTOR SERVICE REWESTOR <br /> ReaussroR Aw <br /> f'r G+ecKM9iu.Rrmmeen C� � <br /> BuameasNAM S <br /> lattoRaa Gar. <br /> MOmE Mauuo A a <br /> FAX e <br /> STATSr L'pr <br /> R L t 6a�.AC NOWLM%;XMENT,; 1, the undecol8nad property or bueinae owner, Vernier or xuthoriaCtl aesnt of some, <br /> ackeewty wI Chet all site and/or profoor 3pothiC ENv1RONMBNCAL HEALTH MI'Aft"T hourly charges euocti ted with chis project <br /> Of activity wIA he billed m mo or my budneu as Identified on this form. <br /> I aiso certify that r hAvii prepared this application And that the work to be performed will be done in necordanee whit ail SAN JOAOUIN <br /> COUNTY Ordlronre Codes,Sian TB,I fiDP, Inw,. <br /> APPLICANT'S SIONA ATM!_ <br /> T M! <br /> PRareaTY l Bumoa owNRtt O Or6MTOAfMANAQaR�0T1IRRAtM400 {DACL^rC3 <br /> APPLC1Nr fa eat IDs�IIA,�'APAMfE Bl/L'LLAS?Y <br /> ff proojofaerAorharron/o 4ltn fr ngafred rnlr <br /> �fjjQ,�lMAT10N 7t3 R6 NSrounsAmnw;When applicable; 1,the owner or oparetor of the property located at the <br /> about rite address, herby IN O COMMMc release E Tny and NI resulu, geoteehnicat dela and/or environn eruithlle eRacum Cnt <br /> In provided <br /> tto to the SAN JDAQUIN ive. BNvrRONateNTAL HSALT9.DVPARTMWT u Rate ae it Is avellAble and At the slime Lime it la <br /> provided tU me a my representative. <br /> TTPEOFsemlceReau±arlb: <br /> EA YMENT <br /> CtST cn1C9 ,4c,e ED <br /> Ouaasom. <br /> JAN 1 2010 <br /> SAN JOAOUI COUNTY <br /> ENVIRON ENTAL <br /> HEALTH DE TMENT <br /> AccarTee BY: O LL J E{ fiMetDYee a: p.3 <br /> DATE; <br /> ASalONfO TO; !� f,� i <br /> B '4 LSU.-� &/XCTee a: L.�-/�.� DATt: � f <br /> Date Service Completed pf alrwdy eomaulotl); 9aaR¢Cope: 6 p E; 2..30(0 <br /> Fee Amount: 34—.5.CGO Amounl Paid 1$ <br /> Pa mart T 3 S- 6 CQ Paymerk Date L I( I D <br /> Y Type invoice CheckM <br /> �( Received BY; <br /> I <br /> EMO 40-02-035 <br /> R6M6E1)I IN 74003 SR FORM(0010en Rod' <br />