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Mat 2O 04 Od111a [ arrie Grownr• •- <br /> SAN JOAQ*COUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID# SERVICE REGUE5I# <br /> Amo -7z rloo 3 <br /> OWT[ERI CITATOR —_ CHECR if8a.41N0 ADORE$S� <br /> FACarzr NAME ��C, IIon O <br /> SNEADDRES$ Ir150 l"�• W\�JOY1 �`= S�c�CK,i•t�r �S.ZUJ� <br /> J.A City- Codo <br /> St at NumNer DI of <br /> HOME or MAILING ADDRESS (if Different from Site Address) Li Cerl�f Cput ll''�--. 'pC• <br /> r 9t e[N <br /> CITY STATE Cq ZIP <br /> � ,c AC,1 <br /> P NE#1 EST_ APN If LANDUse APPLICA110N# <br /> o9) �1 � s - SI-5 <br /> PHONE#2 2U. NOS DISTRICT LOCATION Cope <br /> CONTRACTOR/ SERVICE REQUESTOR RRR tit <br /> REQUESTOR ` CCHACK if etcuvc ACORES <br /> Z l? - <br /> BVS,NC39 NAME I PHONE t1 ` - <br /> �' (^C. C-fl7C TYl Cl <br /> HOME or MAILING ADDRESS 14,2 <br /> CIIy��S_t_tL� <br /> STATE 11G ZIP <br /> BILS rV ACKNOWl'YED EMEVT: I, the undersigned properly or business owner, operator or authorized agent of Same, <br /> acknowled-ge that all site anNor project specific ENVIRONMENTAL HEALTH DEPARTNIEN'r hourly Charges associated'sith ties proita or <br /> activity will be billed to me or my business as identified on this Corm. <br /> I also certify that I have prepared this application and that ibe work to be performed will be done in accordnncc with all SAN JoAQuw <br /> COUNTY Ordirimlce Codes,Siandards,STATE and rEDERAL IaWSS. <br /> APPLICANT'S SIGNATURE: W s-Yr t.— DATE: <br /> PROPERTYJBvSINESSOWNER❑ OPERATORINANAGER ❑ OTHERAurHORIZEO ACENT' VLA i� <br /> 1f.4PPL;CAAT is;of a BILLIMOPAR2Y.proof of authorization to sign is required Tltte <br /> AUTHORIZATION TO RFT FASB INF MATION: When applicable,T, the owner or operator of the properfylocatedat the <br /> above sits address, hereby autltor[ze the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUM COUNTY ENVIRCNMEN7AL HEALT!f DEPARTME',,T as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> CONMENrs: MAY 18 No0 <br /> SAN JOAQUIN C'I <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE. r© <br /> r --. EMPLCYEE$[ DATP.: <br /> AS$1GNED To: j <br /> , <br /> Date Service Compleled 1HalroadycomplatadJ: <br /> SERVICE CODE: I� PIE: 2319 <br /> Fee Amount , vo Amount Paid P�a•'i9,aa Payment Date <br /> PaType ,/ <br /> Invoice,# Cheek# gtft(•3 Received By. <br /> SR FORM(Goldan Rod) <br /> EHD48-C2-025 <br /> RF715ED 11/17/2003 ' <br />