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03/11/2008 TUE 7: 38 FAX 2094'"3433 SJC EHD 0002/007 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If t3LumG AODREss❑ <br /> 411- - l� <br /> FACILITY NAME G 1 <br /> SiTEADDREss �4OA-7Ip / G✓�.EA l4 PE 5� LnTI] T --Kp 953 <br /> Str NOMer I DIF041IMP Stmt HIM ---Cjty ft ewe <br /> HOME or MALING ADDRESS (If DINemnt from Site Address) 4F1 aS`- <br /> g1nel SNest <br /> CITY STATE LP c:�vj ; q <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> rel) 270 - 519 3 H(v- <br /> PHONE#2 SCIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuEsTOR� CMCKUBILLINOADDRESS❑ <br /> En <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAA# <br /> A R ( 1 <br /> CRY 130CAS1f-� C3. STATE / /- LP g0(p2,1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator <br /> tor or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT• nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /�/ <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/MANA ER ❑ OTHER AUTuoRIZSD AGSNTO P/2✓ cyr. <br /> V-APPLJCA,VTis n 1 theI. N ARTY Proof of uthorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE FO ATION: When applicable,1,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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it lSI-� <br /> provided to me or my representative. M� Q <br /> TYPE OF SERVICE REQUESTED: i,--F Tn,✓ Ft C <br /> COMWNTS: Mr'IR 13 [oua <br /> MAR 1 ;; 20088WJJppOUIN O ALN <br /> ROHM <br /> ENVIRONMENTT AL <br /> \HE�H DEPA <br /> ACCEPTEDBY: Cc k'.A- EMPLOYEE 0: <br /> ASSIGNED TO: /- C EMPLOYEEM [!'7 C` DATE: 3 <br /> Date Service Completed (R already completed): SERVICE CODE: �(rQ' PIE: 2 3cS <br /> Fee Amount Amount Paid "tL, QU Payment Date 3 3 U g <br /> Payment Type v' Invoice# Check# s S Reeehrad By: N Cs <br /> EHD 48-02-025 SR FORM(Golden Roe) <br /> REVISED 11117/2003 <br /> X618 - g4L- �64� <br /> X14 SISI - �o`)s" - cpll <br />