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12/02/2008 14:42 FAX 9133712540 BZMAINT X003 <br /> VIRONMENTAL HEALTH DEP TMENT <br /> SAN JOAQUIN COUNTY EN <br /> SERVICE REQUEST SERVICE REQUEST# <br /> FACILITY ID# SZ <br /> Type of Business or PropertyCn A yA r)D6-- <br /> 6 S-7 A-7 I6N Co Lj V CMECN if w , uy aRE98 <br /> OWNER OPERATOR M <br /> v VC-v (i(iC <br /> FACILITY NAME <br /> rt lei o ^ Q M <br /> ACIR g 215 <br /> SITE ADDRESS I,Q 1 ` dG�'►�N / <br /> SNu <br /> HOME Or MAILING ADDRESS (H DHhront tram site Address) r ZIP <br /> $TATE <br /> CITY <br /> Ext. APN>r LAND USE APPLICATION• <br /> PHONE0 �.j <br /> ( ) / BOB DISTPoDT LDCAnoN OODE <br /> e>R. > v <br /> PaoNE#2 <br /> ( ) UESTOR <br /> CONTRACTOR/SERVICE REQ <br /> CnECN N%6w�At1EBW❑ <br /> REOUES' JI O CEV.BUSINESS NAME I-„ �`l ``J � 1'1� j^ � �I� P <br /> HOME Or _ e _ E C) - <br /> STATE XIP _ n <br /> CITY <br /> rwlr erulvOWLEDCEh1EN2: I, the undersigned property L H DEPARTMENT <br /> owner, operator ge authorized agent s same, <br /> !tm 'w edge that all site and/or project specific ENVIRONMENTAL HEALTH D3PARTMCNT 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 anihat the work to be pformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Slandardr,STATE and i's s. <br /> DATE: <br /> APPLICANT'S SIGNATURE: <br /> PRorERTY/BUSINESS OWNER OPERA ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> fAPPLlCdNT Is not the!i LIN ARTY prDOjOf aalbOrlZaNae to sign is required <br /> Title <br /> UT AT Y ' EL SE FO AT N: 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the salve time it is <br /> provided to me or my representative. I-E C E I V <br /> TYPE OF SERVICE REQUESTED: <br /> CONMENrs: DEC - 2 20OPEC O 2 21009 <br /> SAN JOAQUIN C5U4W0iVN11NI f HEALTH <br /> ENVIRONMENTAPFRt,1lljT/Sl--R\/ICES <br /> HEALTH DEPARTMENT - <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> Date service Completed (It already completed): <br /> SERVICE CODE: l PIE: <br /> Fee Amount Amount Paid Payment Date (j <br /> Payment Type Invoice# Check# Receive By: <br /> SR FORM( den Rod) <br /> EHD 48.02-025 <br /> REVISED 11/1712003 <br />