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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bualtasas a Property FA lD d <br /> SERVICE REOUESTtI <br /> OWNER OPERATOR S(Zuc y (�I <br /> "`''L c CamcKifBau�awooRF�❑ <br /> Fpm NAME <br /> Sam ADDRESS <br /> HOME or MALMO A000m C <br /> (M OMfarrrrN fYotn Slee Add►aas) <br /> Cm Nam. <br /> STATE Z?P <br /> PHOONE�;r(1 G Ev APN R <br /> 1 `- 11 �, - l ( -(CJ LAND USE APPLKATtQN N <br /> PHONE02 En.L-( I SOS 17"CT LocATsm CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR <br /> BUaa6SS NAME !>titaE# <br /> �E'rTap 3c.z 1` (v� tI- 7 Z <br /> HOME or MMUNa ADDREft 2 -7 <br /> FAK# <br /> QTY Z- 1-:a Z <br /> sTAlE �,y �P �, ��y <br /> I, the undcrsgpod Property or business owser, operator or authorized agent of same, <br /> acknowledge[hat all site and/or project Specific ENrVMONMENTAL REAL IN DEPARTMENT howdy charges associated with this project <br /> OT activity will be billed to me or my bmluess as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUtN <br /> COUNTY Ordinance Cortes,Standards,ST laws. <br /> APFUCANT'S SIGNATURE" T <br /> UATF: <br /> PROPEaTY/BtnClr�asONNrAO OPERA Q>Hf�At17HONhZeDAtskNTl� <br /> j: <br /> if APPLicANr is not the �c- <br /> c--- <br /> a r Lada a to sign is required Titre <br /> AUI'HORMA ION TO E eta When applicable, i, 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 andior environmentaVsite assessment <br /> information to the SAN JOAQt"COUNTY ENVIRot MWfrAy HEALTH DEPARTME?4T as soon as it is available and at the same time it <br /> provided to me or my representative, is <br /> TYPE or SERVICE MO., t1^0%� _ ,��T-7 _ Lt1T09-�( �F(.F <br /> MAR 1 6 2006 <br /> At:ctgQOMPI*�ted <br /> BY: AOUW COUN <br /> aCQn%g@ftd): <br /> E.IIIPLOYEE ty: �3 W►Te 1A831GN ED nO.EE>E: s3 D�Tr '3Oalo SoCooE: PIE:Fee Arrwmorutt Ptrdd00pailawnt DatePayment 16 <br /> C�I/eit S( 2 ReoaNred sr: C� <br /> EHD 4e-02-025 <br /> REVISED 1111 7r.,= SR FORM(Gdden Rod) <br />