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09!29!2005 trE❑ 11:02 Fax 2096663633 SJC BUD --- Stockton Sa_v Eta V9 Co <br /> �,6az/uoa <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.FIEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACtLRY IP# SQtVICE REQUEST It <br /> Type of&wlrwss a?rOPErd <br /> I)y.Rlek . CMEcaclf BaAINC <br /> Fac YNAME v <br /> SrrEAuDRESs )5� I <br /> horEorIAAEJNGAucaess pfCifinemtrwnantAddress) <br /> SIr•J[NJflho� <br /> STATP ZIP <br /> CM <br /> An. APN k L. Use APPL.ICAMN a <br /> pxva Ci J <br /> i I <br /> USrNI(� LP A.1 Ou0e <br /> PIgNEt2 <br /> F>,r, 9O9 <br /> l <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REOUESTTIR owErxlf @)_w+o AanEEs6❑ <br /> f PNDNE Yrs Er. <br /> Ewsil NAa7 Go <br /> Frye Y <br /> ivig <br /> HOME or MAIURG AW lis 6 <br /> STATE TlP <br /> Cm <br /> BILLING ACKNOWLEDGf�M�14T: 1,the unaersignad property or busieoas owner,operator or gall at"'at same, <br /> acktl9wledge that all site and/or project apeciftC E.NVMQNMENTAL Hif�l.Ttl DEPMTMtTNT hourly charges associated with t?lis Project <br /> or eco vity will be billed to me or my ba d11ri as entified on this Corm. <br /> 1 also certify inat l have prelat this appliratio d that flu worx w be performed will be done in accordance with all SAN JCAQ�iN <br /> COUNTY OrduL4+xe Codes,Sfandvds,STATE an EtAL laws. 6 <br /> APPLICANT'S SIGNATIAtg: DATE: <br /> On[aa AUritam3a0 AcxNT❑ <br /> anOYaNry11{tI61NPs10wNP.n� O"R / NA Tfllr <br /> ()'lIPPI1CAA71.5'Na rhe BILi4NC E!tJa flroo Of RatlI0Yl7!lli0a la 9{b'a is regalydd <br /> OkJZAT10N TO Rg[.¢ASE INE0 kMAT1ON: When applicable,1,the awaer or operator of the pr011 located at the <br /> above SW address, heroby authority the release of any and all reseYts, geoldehnical dank and/or mrviro"McuWlsire asac9arneat <br /> information to the SAN]OAAUSN COPKr'y RNV120Nt4EWA1-HEALTH DE'ARTULNr as soon as 1C is avallecle and al tilt sues:bmC it is <br /> provided to me or my eEPresenfatio' <br /> TYPEop,SERVIGFRE4uS'1Fn: <br /> Coawvna: <br /> EMPLOYEE DATE+ <br /> AtxFPTED t3Y: <br /> EMPLOYEE b: OAC <br /> Asa10 NEoro: P1Eo <br /> Date Servlu Completed 01f already compMlad): <br /> SExAcerAOE: <br /> Fee Amount: <br /> AmoWtt Pald PttymanE Date <br /> e# CheekR Received 8y: <br /> Payment Type Invoic <br /> SR FORM(labiden Roe) <br /> END 4692-026 . <br /> REVISED 14117/2909 <br /> Z 99Z990L992 151.11.19EL 3 AGAOO 869:90 01 9Z AV <br />