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11/30/2004 11: 5; 2094683433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN )UNTY ENVfRUNMENTAL HEAL'TF TARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SEWICE REQUEST# <br /> 3*0 <br /> OWNER/OPERATOR <br /> P /A I L O CHECK If SILLINg ADDRESS <br /> FACILrrY NAME <br /> SITE ADDRESS �cNC reallr may SAOC-V-ion �55ao� <br /> p <br /> Strefit Number DlrecUon <br /> street Nsma cityZip Code <br /> HOME or MAIL1140 ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY LA <br /> A me STATE zip�H G 0C0Zz <br /> PHONEM EXY APN# LAND USE APPLICATION# <br /> PHONE#2 T SOS DISTRICT LOCATION CODE <br /> CONTRAC'T'OR/ SERVICE REQ-UESTOR <br /> REQUESTOR <br /> J evk vinL CHECK i!BILLING ADDRESS a <br /> BUSINI•SS NAME (� T+ PHONE# EXT. <br /> LOCA-kn-e- YC'.r t Nc• (1- 1 - <br /> NOME Or MAILING ADDRESS, �;n /'TU� ��,�` ,I � FAX(� <br /> CITY L_xAL C (�` STATE CCS ZIP VJ <br /> BILLTNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI4 DEPARTMENT hourly char.-es associated with flus 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 JDAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE- and FEDERAL laws. J <br /> APPLICANT'S SIGNATURE: ��, L�✓�---- D���: I Z- 7-O o'( <br /> PROPERTY J BUSINESS O%XN, 1&t ElOPERATOR/MANACRR ❑. OTii.FR AUTHORizED AGENTIs T(�,,o�C C7 oAahQ`-�e+� <br /> If APPZIG4NT is not the&LLINGPARTY,proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE MORMATION: 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, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN.COUNTY ENvitONNIENTAL HEALTH DEPARTMBNT as soon as it is available and at the same time it is <br /> provided to me or my representative. /� <br /> TYPE OF SERVICE REQUESTED: ��� P'I !V C^f 7 t i2— � �E� �\��— <br /> COMMENTS: �E� o 2004 <br /> SAW JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: CA- U� T�� EMPLOYEE t: ©3 2i DATE: <br /> ASSIGNED TO: - ��S�J EMPLOYEE DATE, [c i <br /> Date Service Completed (if already completed): , PIE: <br /> 3 <br /> Fee Amount. :,..' '=2�?f, Amount Paid. D Payment Date. q <br /> Payment Type ^;� Invoice# Check i77 Received By: <br /> EHD 48-02-025 SR FORM(Golden Ro <br /> REVISED 11)17/2003 – )f <br />