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Jan 31 05 10: 30a Christina Gill _ 707-3GO- 1307 p . 2 <br /> JAN 31 2005 8: 18RM L DESIGN GROUP . 765 9908 p. 3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL REALM DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bitilans or Property �U.AY In SERVICE REQUEST* <br /> �Df <br /> To wl -ra.a�t FL1Eivlc� c.�.� :.J / 5200.E i so q <br /> OWNER I OPERATOR Cxsor r&LLerO ADDREIe <br /> r_ cp pL_ N 1 L iG <br /> FAc&m NAME <br /> SIADDRESS yfL� 1C•�-TN 171). �Lrv+!?nP 45'S'3o <br /> HDNE or MALWO ADDRESS IN Dtflwwd from sue Addrese) 14no I J1/- Dd T7b4 AVE•J ,7;C. <br /> Cm STALE LP <br /> -!>qrl TA G CA ei 54 CA <br /> pip Dir• APNE LAND USE APPDGATION0 <br /> (70-7) OZ+p --I-O <br /> PN Era BOS OSSTRIGT LorJ1TIDrr CODE <br /> (70 ) 4PO- e,-ZZ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Crarcrcr BiLuticiApagEssEl <br /> BusNEss NAME PHOW# Ev- <br /> JA-+-+veil- - <br /> Horse or Mmtate ADDRESS FAX# <br /> 4'4-1C> Ito <i 'Loo ( - OrIll <br /> crry IF- $TA AP <br /> BILLING ACKN0V LEDGEMRN7': I, the wrdmigned property or business owner, operator or autborlmed agent of same, <br /> =knowledge that all site and/or project specific ENvIRONa1ENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activitywill be billed to me or my bcstaess as identified on this form. <br /> I also certify that I have prepared this application bLatthe work to be performed will be done in accordance wab all SAN JOAQDIN <br /> COUNTY Ordinance Codes,Srandar&,SrA' r }�ws. <br /> APPLICANT'S SIGNATURE: iC __ DATE: <br /> PROPERTY/BuslsEsa OWMR Of, 0?I TOR noxa❑ OTxERAUTRORDDLDACETT❑ C G/ <br /> IfAPpuGIMT isrw11he BaLW(7 PA7gTT proofofudsorkadon to sign b re¢aired Vile <br /> AUTHORIZATION TO RELEASE INVORM)UO; Wben applicable,1,the owner or operator of the property located at the <br /> above site addrm, hereby authorize Lite mlm,;c of my and all results, geotechnical data aallor eoviroamenmlJsitc asses t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me,or my representative. J <br /> TYPE OF SERw_E REquEsT®: E( S T <br /> comatw l pt,QrJ Grr'G�� k, e¢a3FLT P�Cr•rtTt- �cC p Z, it A�f•G A'To( r/X-K <br /> /� id ttP sa. ff. ua�oPt t fir) 3; 345 sra_ <br /> G AriOC'lr l3) ZO, ouo fi 4l. tt�J?y r L1� 1o,OD0 CiA� Ot7 GL LL9WA&nCA-t• 0 .--f <br /> Ar+D Lt S, leo Sta. IF-c. R+_Ynt� a., . <br /> Ac E"w8Y: CJL VAIrel EMPLOTEP.M .3Z DATE: 3 <br /> ASSIGNEDTO{ rfL),J Fa j. fMPLoyEES: 3 1-7 DAIS ?,'/I 0C <br /> Date Service e=Ialied Of already completed): SEMME OWE: 03 i PIE: _�)2. 03 <br /> FeeArnoonC ' -7 q (,UO Amount Paid 41,t � 50 1a095Payment Date 3 ( � p�' <br /> ft rnent Type L,�- Irnolw 9 hsdr U ZS bl I--2 � Received Bye -2 <br /> EHD 1502-025 y"�"' ,/'2i 9�-- /L L.SU/ SR FORM(Golden Rod) <br /> REVISED 1IM7J2DD3 <br />