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JAN JOAQUIN 101.1KIY EN VIRONMEN7'AL MI;AL'1'H UEPAR'I'MLN't' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID/ SERVICE REQUEST/ <br /> f n 6b <br /> OWNER J OPERATOR <br /> JOFI'n1 CrAcSN CHECK MBR.IatO AODIrEae® <br /> FACI"NAE j2(2_lC W 1 NE'gj <br /> SITE ADDRESS 15-(v 1-& 1J . I AL-Plije IZD . L-oDI 9S7-1Fu <br /> se.« <br /> HOE or MAR=ADDRESS IS DNbrent from AN,Addrwa) SN vN E <br /> 80ert Numbw shyst None <br /> CITY STATE BP <br /> PHONE#1 Ear. <br /> LAND USE APv <br /> 1925) -384-(019 -4 oS1 -O-4-0- 1p I-x-00l -00I (SA) <br /> PHONE 82 E= SOS DISTRICT LOCATIONCoce <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECt mfr PtDBy RfrcC-O SLLM ADDRESS❑ <br /> CIffCr(M <br /> BUSINESS NAME LIVE OAK-- �pENJItZUA/w7Et✓TA L_ p2p9 3109- o3�s Ext. <br /> NOME or MALMD ADDRESS 40-} KJ• OAK SR• FAX II <br /> (7-01) <br /> CITY L OV 1 STATE GP* ZIP 9'S--` 0 <br /> I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I 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,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATURE: DATE: )O�y 1(,LD i 3 <br /> PROPERTY/BUSINESS owNEnp oeeRAToR/MANAGER ❑ Oteres AUTHOR, AGENT O <br /> if APPLICANT is not the BILLINGPAeTr. proof ofauthorikedon to sign is required Title <br /> AUIBURM&IION TO RELEASE EffORMATION: When applicable, I,the owner or operator of the property located at the <br /> above sibs address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br /> information to 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: KIWI.EW SOI L— SG ITA•ii►L rT y l iv m�E LOA> S'Tvt��f <br /> CoalENrs: 5/x//3ECEIVIvr <br /> ED <br /> Es«-& �p""^ ) L C)�aN MSR 11 2013 <br /> JogQUIIV C <br /> NEq-TH pOMEry AUNT 1 <br /> ACCEPTED BY: EMPLOYEE III: DATE: / <br /> AsSKN*ED To: EMPLOYEE#: DATE <br /> Dabs Service Compkebd (M already Computed): SERVICE CODE: _ — P/E: 2 O <br /> Fee Amount: BO Amount Paid 6-J6.0 D> I Payment Date 3//,//j <br /> Payment Type Invoice N Check# 3667 Received By <br /> EHD 48412-025 SR FORM(Golden Rod) <br /> REVISED 11/7712003 <br />