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FROM : CENTRAL VALLEY PHONE NO. : 2093425109 Feb. 23 2006 11:43AM P3 <br /> 02/22/2006 12:01 209460`...W4 Lrw <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> ENA�ft <br /> ProP" FACILITY ID M SERVICE REQUEST <br /> R CtlECJ(1f 61LLINb AMRES513 <br /> nuioc7 tzk�tp].Ztxa <br /> ADDS Charter stock 95206-111 <br /> 17139 SbaflN M aM ,.. <br /> HOW or MALMO ADDRsS (If DafeNnt from Situ address) <br /> Steel Nu sNaetN <br /> CITY STATE ZIP <br /> PKMi♦ 6X1'. APN# LAN UsEAP ucAT1oNi <br /> ( 209) 969-5200 <br /> PN S EXr. B08 DISTracr tACATpNtom <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTDR CHECKNBIWNGAo els0 <br /> Same as above <br /> BttalNEss NAME pNONEi °". <br /> HOMEor Iimums ADDRESS FAX11 <br /> ( 1 <br /> C" STATE Zip <br /> SLING AC 2414)MM <br /> DCE'NENT: I,the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all she and/or project speeiSe FNvllmoxmeNTAL 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 applica-Ion and that the work to be performed will be done in accordance with all SAN JOAQuw <br /> COUNTY Ortftm Caries,Standards,STAT;Ilrld BiiAL laws. �/j <br /> APPLICANT'S SIGNATURE: I r DATE: a-� <br /> RROPX. I RusVmEss 0"rsaK OPERAnO 1 NIA.NACan Cl OTRnt AurxoRrmn ACENT I� <br /> JfAFFLtGINT is rmt the <br /> P TY proof of aathorizadon to sign is requited Title <br /> AU'T'HORIZATION TO REr'RASR INFORM6J20�:When applicable,I,the owner or operator ofthe property located at the <br /> above site address, hereby authorize the release of any and all results, Seotechnicai data and/or elwironmentaUsite assessment <br /> information to the SAN JOAQUI N COUNTY FWVIRaND ffiNTAL RrALLTJl I)PPARTINENT as soon as it is available and at the same time it is <br /> provided to no or my representative. <br /> TYPE OF SERVICE REQUESTED: UST Consultation <br /> COWMTs: <br /> ACCEPTED BY; EMPLOVEE M; DATE: <br /> ASSIGNED To: EMpLoYEE M: DATE: <br /> Data Servicecomplow (Rak"OreomPleted); SEmICE Cove: PfE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice M Chaok i! Rec 4ved By; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISEo 11177!2003 <br />