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CiY( VJ/ LV4J 1.La 1G GV JYV VJ I 111 11I I LV VI\ I I-�Vl, uJ <br /> SAPI J'OAQUAUNTY ENVIRONMENTAL$EALTH DEI ENT <br /> SERVICE REQUEST <br /> :E0O <br /> Type 0711 iiolness or Property FACILITY ID# SERVEf EQBJE:ST* <br /> 7 0 -. <br /> OwuFtsi OPert,:TOP --- - <br /> asT��L'niT Row fj L66 ^AMaEss f <br /> FAM n RAM E <br /> - <br /> _ya'�3��;umDer ol(sc2fon t••�'V��f�I�� J t t`rC'�1 �jS V tr't�-1��� C.7,r��!' ' <br /> l NaMe C,�...m.W 1 eio CG�e <br /> �IOfi;Eofi l!?ARJilO A60RF,$.j (Pf DNhrani4rom Site Address) - <br /> smut Numoer vc a u-ma <br /> CIT, STATE zip <br /> A �a. APN Yr <br /> ( V1N0 USE APPLICATION,I <br /> 605 Dm7T ILocAna+Con-: <br /> t I I <br /> ---CONTRACTOR/ SERVICE REQUESTOR <br /> �� RECLEi^TOFl-TOR r. <br /> i`111, -D �� CHECrY,M ISI:LING AoonE.=5 <br /> BLEmESs NA!!iE <br /> ttCME ar YiAiJtlG r`3OOP,c^a FAX#eu <br /> !� <br /> i M L0 9 i STATE /'T II ZIP <br /> BILLING Af'S'NOWLEDGEMENT: I, the undersigned property or business owner, operator or authe Erized went of saute, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chats wsoclarcd with this prof-at <br /> Or activity-0.111 be billed to me or any business as identified on this form. . <br /> 18150 cwtify?hat i Gave prepared this application and that the work to be performed will be done in accordance Nftt all SAN JOAQUIN <br /> COUNTY Orurinancs Codes,Sidrr4ar4Z,STATE and FEDERAL laws. <br /> APPLICANT'S SIGAIATURZ: % ,f DATE; 4' A4Q 0 <br /> FRojp .!B-LSr.+Ess0", 9RQ OrSw'roa?MANAGER OTusRA=oa=OAoanT0 <br /> Ij�lIJ'PI1G4N'T is trot rhe R!rl1NG PgRTY,proof Of trullsonzadon to sign i5 required <br /> AUTHGRIZ.A x(C7N TO RELEASE INFORMATioN: When applicable, I,the owner or operator of tae proverny located at the <br /> above site addrm, hereby authorize the release.of any and all results, geotechnical data and!'or rviron+ue„t51!silt; easessment <br /> infor 6012 to the SAN.IOAQULY COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it s ivailabic and at the sern-c time itis <br /> provided to me or my rev <br /> resaltztrve. <br /> [TIYPEOf5EavicepEOUEs r�: /MD k:;iQ REOEiVEO_-._ <br /> APR 41005 <br /> EPN JOAOUN COUN[—Y <br /> F�JVIRCitiMH'�'FrV4. <br /> —�-7 HEAUH DEPAR7MENT <br /> ACCs-P _'O S*Y. f t YEE#: Gjfj/ !^•Y <br /> ASSIGNED TO: EMPLOYEE#: IV '�_I� DATE: <br /> Date Service Completed (it alraadyCompleted): SMVICECODE: PJ B <br /> Fes Amount: �" Amount Paid a M�- p Payment Dale / ,. <br /> r 0 <br /> ParmentType M/ Invoice# Check# J✓ Recae°, it F-Y' <br /> P. <br /> 4Z0 <br /> 11!17!2 <br /> 1!1S 0 SP.FC�P79 iw41dm Rotl) <br /> R1^,$cD 9i?97'!26.73 ' <br />