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-' SAN.IOAOUIIN COUNTY ENVIRONMENTAL HEALTfIDEPARTME1%-T <br /> SERVICE REQUEST <br /> Typeof Business or Property PACIUTY IB# SERVICE REQUEST# <br /> OWNER/OPERATORS T <br /> 1 U 7—LA/ CHECKH 8111R1p AnnnE39 <br /> FAcurYNAME <br /> SI9 <br /> ADORE39 pNy ���'�7'�' <br /> sheet NumWr airetaon aanol Name i� es' <br /> HomEor MAU110,ADDRESS (tf Daterentlrom SlteAddreaa) <br /> r 5 LHaT^ <br /> CRY STATE zip <br /> I PRmE#i an. APR LAND Use APFLICATM0 <br /> vtI - 4, <br /> NONE 2 s* sos Dtsrwer LeeaTmN coos <br /> 1 ) <br /> CONTRACTOR I SERVICE REQUEST-OR <br /> REvuESTOR <br /> n �` CNecKlf aquao AnoaEss© <br /> BUSINEsa NAME / _ PNUNE tI Exr. <br /> ,719 <br /> Home or MMl.M ADORES <br /> - !' FAUA <br /> j -P f ) p <br /> CITY C C STATE C'•I zo <br /> BILLING ACKNO',VLEDGEMENT:T,the undersigned property or business owner,operator or autborvad agent of same. <br /> acknowledge Thar all site and/or project specific ENVIKONmFNTAL HEAmii DF➢AkTAffi\"r hourly charges associated with This project <br /> or activity will be billed to me or my businesses identifiM on this form. <br /> I also certify that i have prepared this a pl' lion and that thew to be performed will he done in accordance with all SAN 1OAQUm <br /> COUNTY Ordinance Codes,Standgrd A FYIl lap/ <br /> APPLICANT'SSIGNATURrs._,_-- DATE: <br /> PROPERTY/alL4LN OWNERP OPERATOR/hfANAGFR P1 amER ALTIlowun.AGeM1T❑ <br /> ((( If APPLICANT is not Aid QILUAV PARTI'.proof of auyhoriw ion to sign is required Thle <br /> AUTHORIZATION TO RELEASE INFORMATION:Wllen applicable,1,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 mrviromnentaVsite assessment <br /> Information t0 the SAN 1OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMINf as soon as It is available and at the same time it is <br /> provided to me or my repretenradi . , <br /> TYPE OF SERVICE REQUESTED: �S�d'Y(JLfLZ 'Y' [9rJ <br /> COMnrNTS: <br /> ACCEPMtl BY: EMPLOYEE'M: DAM <br /> Assialmo To: EMPLGYEE#: DATE <br /> Date Service Completed (h already eoinpiow): SERMECOW. P1E: <br /> Fee Amount, Amount Pald Payment Date <br /> Payment Type Invoicep Chack@ Received By: <br /> t <br /> EHO 48-M-025 RECEIVED <br /> I ', <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />