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SAN JOAQUI Cf iTX ENVIRONMENTAL HEALT14 DEPAT IMNT <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST# <br /> CLAS St"A--a J Fa 0003715 SR0044312 <br /> OWNERI OPERATOR / - dNECKif BIUINGAooREas1 <br /> FAGUTYNAME .. IV <br /> SITE ADDRESS f] S' �'D �U� -T SL g3,�Q[L <br /> Stne Nu Qire ldn 8ba a 21 Cod <br /> HOME or MAILING ADDRESS llf Different from Site Address) <br /> . - SL2lt NURIPGr street Na e <br /> Cn-Y STATE ZIP <br /> PHONEiH <br /> EXT. - APN# LAND USE APPLICATION# <br /> PHONE#I BGS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR � CHECKifAiLuno AoDRm <br /> cS2YV�(1L E*dtl&41 5*El , t(yCLL�1 uALUA <br /> SwoNEI <br /> SS NAME�j, VecL • �^ [___ ._ PHO �T <br /> HON1E Or MAILINDDYYRG AESs FAX <br /> � RO ll(Vt G1',.-,AL,--e <br /> CITY S 110 S 4 _ STATE L4 fA ZIP <br /> BILLING ACKNOWLEDGEMENT; I,the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site andfor project Specific ENvIRONmm- Al,HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business asidcntified on this form. <br /> I also testify that I have prepared this application and Uiat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordi=nee Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT S SIGNATTJRE: <br /> � �L <br /> I , -!1�1.L1.- -GlL"'�F-1-i.t.,d—t�V - OATS�:a 10r( at C,o L � <br /> P1Rovwn Own <br /> -R BasiNEss OwM❑ OP AroR/mANACTat❑ o=mAUTEOR=oAGr.NT1ZliQy - ecylik rOv <br /> /fAPPLaz&r is not the BiLLm PARrv.proof of autkorkadatt fo srym is required Title <br /> AMORMATION TO MLYASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address,hereby authorize the release ofany and all results, geotechnical data and/or cnviromnental/site assessment <br /> information to the SAN JOAQUIN CoUNrY ENVIRONIvMNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. /1 <br /> TYPE OF SEIMCE REQUESTED: LL 6 7— �rt-C' �tw 9 /T��AA ,�, ��-p,����f -{per p �� .�`(�" <br /> COMNENrs: ^er�--6. ivt- l X,LL 44 yt'1..L7tJL"&M 6XVCL 1Ve'`-'�i%-kWj <br /> �. S s(�ct�al�e u-►'9 r.�d-e.. Yt�azi }� Y�tjt_ived�, J <br /> ACCEPTED BY: ?! EMPLOYEEM. ') - DATE: 10 t Z/O <br /> G =1.CiF! t�--r-C C / Jr <br /> Aa3(atEDTO: EMPLOYEE ft DATE: 10//Z/06 <br /> Date Servloa Completed falreatl rnpletel): BERME CODE PI E: 23 8 <br /> Fee Amount ., 27 OD AMOUntPald Payment Date L011z./Os <br /> Payment Type V Involceu - Chock# II78$ Received By. Wl— <br /> �vrp�oRM Golden Rod) <br /> REVISED f <br /> 1111111712003 - - PAY, V I <br /> RECEIVED <br /> OCT 12 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL - <br /> j4EALTH DEPARTMENT . <br />