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SAN JOAQT' ',,OUNTY ENVIRONMENTAL HEALTV�EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f-po 11/v09 <br /> 9 <br /> OWNER/OPERATOR <br /> C.rlat:+f ff ISN.iING.4trr$.e <br /> t FACturT NAME <br /> I F--Q 5E <br /> SITEAauRiiss 2:t-33q S. �rr1i^A! �• -rt ftC.� 9�30�-4 <br /> $L u rjjwaw strea Nam zip g9de <br /> TOME or MAtLm AWRESS (if Difforent from Sita Address) <br /> gt,� 9i�eet rJ <br /> CITY STATE Zap <br /> FHoRE#1 Err, APN## LAND USE APPLICATION# <br /> (WI) Ct14- t3`'L- WS-0io- 1 0trP,C,S(6-1•JE'D Vp A- lD Vw�� <br /> _FWXE 42 Exr. � � � 1308p18Tlq[C7 LOCI►Tt4w CAQE <br /> CONTRACTOR RACTOR/ SERVICE REQLESTOR. <br /> REQUESTQR <br /> C►UcrxFfV"MAMM ssQ <br /> BUSINE:ssNAME LAQE pkr— <br /> [a�Ot�1�� 1S�o�f��Nt�'tLr AHONE# <br /> - V43LoR� 3 S <br /> HOW Or MAILNG ADDRESS�� ' <br /> CITY L- a STATS C,fA, <br /> BMLING ACKNOWLEDGEMENT_ I, the undersigned property or business owner, operator or authorized agent of sarsle, <br /> acknowledge that all site and/or project specific F- NviRONMENTAi,HEALTH[)DEPARTMIkNT hourlycharges associated with this project or <br /> activity will be bided to nie or my business as identificd oa this fom <br /> I also certify that I have prepared this application and that the to be performed will be done in accordance with all SAN 7oAqum <br /> COUNTY Ordinance Codes,,Standards,STATE and FEDERAL hats. <br /> APPLICANT'S SIGNATURE; DATE: <br /> PROPERTY f BUSINESS OWNEROURATOR I MANAGER OTmx t AuTuog=D A09NT <br /> IJ,4PPGTG4N7 is a t the 1LL1N ARTY proof of uutkorazotion to s8t 4s required Tins <br />` <br /> &TM2&1EZA1CX0N TO MIZAM MEMMAMM: 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 and/or environmtwallslte assesswmt <br /> infarmation to the SAN JOAQUN( 01JNTY'ENvIRQNMT NTAL HEALTH DEPARTMENT as soon as it is available and at the same d xee it is <br /> provided tome or my repzescntatrve- <br /> ENAVEn <br /> TYPE]OF SERVICE REQUESTED: P-O l F-W SO 1 L }`C IP► l L l S"1^ D PAYM <br /> cOMMErrrS: <br /> SAN JOAQUtN COUNV <br /> ENVIRDEPARTMEN <br /> 4iEA�TH T <br /> J� <br /> Acct=PTMED 9Y: Emm-ONFE#: , SATE; c�j r o <br /> ASSIGNED 74: EMPLOYEE#' DATE: <br /> 12 ar;} ,t1 <br /> Date Sorviee Completed (it atready coMpgleted)_ SMMECODE: E)Z PtE: ,K- v <br /> Fee Amount: -2,30 ad Arr►ount Pald �,3� p payment')ate <br /> Payment Type ✓ Invoiced Check# ©(� Received By. <br /> EMD 4M2-025 SR FORM(Golden Rod) <br /> Ri WSED 11/17/2003 <br />