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OCT-25-2010 22:14 From: To:4683433 Pase:7�12 <br /> 2Vq 4& �,673 e- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> P"�NQ' �� 3(4 a0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IdV1C-Clr AL V% <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESSO <br /> FraNCetJel ubav- <br /> FACaITY�E L4kl�>~�► Fir IA-6- �Qt-t� -T-ti C.. <br /> SITE ADDRESS /[fly-t� t )c'2:'e IV<I L� �, -L5 0 <br /> Sine Number ON .'i `S T <br /> HO E Or ILIN ADDRESS (If Different from Site Address) <br /> I <br /> Ser [Number Ser [Name <br /> STATE zip4.s 3 a <br /> TY -r-ra� <br /> PRONE#t <br /> Exr. APN Y LAND USE APPLICATION X <br /> (ZcR) $14-3-7�-2 -P <br /> PRONE 42 Ext- HOS DISTRICT LOCArION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr L/� ��aj r H CK if ILUNGADDRESS13 <br /> r �,� cabciY V Ex.. <br /> BUSINESS NAME PHONE — <br /> HOME or MAILING ADDRESS Pao lags FAX <br /> 1"' r O G.LrI �I <br /> CITY 11i tj de-0 $TATE zlP q gZ3 <br /> BILLING ACKNOW_I_-FDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project speeifio ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed W me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDERAL law , <br /> APPLICANrSSIGNATURE= DATE: <br /> 1 �[q <br /> PROPERTY/BUSINESS OWNS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Id <br /> IfAPPLICA is not the B/LL6YG PARPY,proof of authorization to sign is required Title <br /> AUTH0 RI ATION TO RELEASE INFORMATION: When 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 environmental/site assessment <br /> information t0 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> (� + rD -Fri- pla �iAZg 2`�/5� /Ny <br /> I Ng Q rn= qa 1� D 0.4Da <br /> 1284 <br /> QUICKI KLEEN CAR WASH <br /> PH.209823.9159 <br /> 707 E. YOSEMITE AVE. <br /> MANTECA,CA 9=6 Sp-329p/12t1 <br /> DATE I <br /> PAY <br /> TO THE <br /> ORDER OF <br /> RFC"Na/ier,.nl 61r Nerth 7in Stmrr A <br />