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Oct 15 04 10: 49a (2096784-0112 p• 4 <br /> FIFTH FLOOR PAGE 02 <br /> 10/14/2004 16:09 2094 33 VV1,. r vu vk iwrLNiAL"EALTH DEPARTMENT - <br /> SERVICE REQUEST <br /> Type of Ru/slintsa or PropertyFACIL Y 10 P SERVICE UESI C <br /> LO 'IF _ c �. j �X � ''--tt <br /> OWNER/OPERATOR GrKCK it SIyLsIo AOsgE53 El <br /> v\ <br /> FACaOT MAML <br /> Y /� `1 _ <br /> SrrEaDD ss Nor 1 , / <br /> Note or MA Lm ADDNess (R Diffelera from sits Address) 'e..� <br /> CITY STAR' ZIP <br /> p Exr. APR$ Lana USE Arra TION C <br /> p Fz Bir. SOS D ATP1eT LocAtbli Cone <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUSSTOR --N CN6CKItA.LW*ADQ-,U <br /> Lam- �1�• w\ynn <br /> 8UsINESS NAML PHONE* . <br /> J- <br /> HOMEIrr GADOREss FAX <br /> 9 ) 9L1OI / � <br /> Cm STA Zip <br /> 13`�LINC ACKNQWLED9F1MM K. the andeniped property or bums owner, operator or authorized ergot of tame, <br /> aelatowledge that all site and/or project specific ENvJRONMENTAI.HEALTH DPPARTMENT bourlY cbArM associated with fhia project of <br /> Activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be pcefocmed will be done in accordance with all SAN JOAQULN <br /> COUNTY Ordinance Codes,Staffd ids,STATE an FIDE laws. _ <br /> APPLICANT'S SIGNATU <br /> PnortaTr/BUSINPS6OWNFR❑ prEa:nT0a1 MNNACER ❑ OMR ANn0atExQ ACKnT Y i� (_Q_•_ <br /> IJAPPUCaMir nor rheh'IIPARrr.pnsOJoJaixhorhatioK ro.tifiw is req Two <br /> At�gfty 4TION IO RET EASEL INFORMATION; When applicable,I,the owner or operator of the property located at The <br /> above site address, hereby authorize the release Of airy end all results, geoteclolle2l data and/or environraaomysite assessclent <br /> information to the STAN)OAQUIM COUNTY EN%7RONMENTAL HEALTH DEPARTMENT u soon m it is available and at the same time itis <br /> provided to Roe or my representative. <br /> TYPE OF SERv1CL REQUESTED: <br /> Masons: ICT 1 92004 <br /> SAN JOAQUIN C <br /> HEA TN DE ARTTAL TY <br /> AcccPrta evt C7 t.r LIE 1,�<1 EnwLorEc q: L'`y 2 DATA: l G' l `1 G r <br /> ASStOgw To: I>_ EMatarn s: '7 3 P-7,1 aur: r 1 r o <br /> Date Setnric Completed tit already co pmad): J D SEaNIClGOOL: ! PfE: ` '>. 'Ob/ <br /> Fee Amount Amount Paid — PaymaMDaSa �B_ lq <br /> Payment type ktvolco 0 Ckeok 0 1 Rsosived By: <br /> EMD 48-02-025 SR FORM(Garden Rod) <br /> REVISED 11/17/2000 <br />