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h Oct. 13. 2 .5 4 45'VOAQ N—'lVLACH z&� P IRZZRAAINCv MFN_F_aL-HEAL:I-H D> PA�z=rr �x0297 P. 2 <br /> 01:'. <br /> ; � .,. _ <br /> ., I SERVICE'REQUEST <br /> Type of$usiness or Property FACILITY ID# SERVICE REQUEST# <br /> 111" OWNER l OPERATOR <br /> CNcCKifBILLING ADDRESS <br /> I FAt,ILITY NAM>~ <br /> AeA <br /> SITE AODRE$S <br /> 0( 117 <br /> tion Street Name Cit 2i ode <br /> I HQME or!MAILING ADDRESS (If Different from Site Address)C1 zip <br /> TY AWE <br /> YrN <br /> t9zS��� •oda � /G� _ <br /> EXT_ CO SOS-DISTRICT—- �4�',-.- .-.LOCATIO C - - <br /> CONTRACTOR/ SERVIC'_IZ REQUESTOR <br /> PFQUE-171A —STOR y/ CHECK if BILLING A>ZDRE55 <br /> PIZ <br /> �r7 /h///22] _ <br /> . BUSINESS NAM€ Wk-)0sa.r • PHoNE# <br /> Q — <br /> HOME or MAILWG ADDRESS FAX# <br /> CITY <br />'4 / y f G — STATE/e� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator Or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAi.HIEAI-Tri I1rPARTMFN'r hourly charges associated with this project or <br />` activity will be billed to nae or my business as idea ihed on this form. <br /> 3 I also certify that I have prepared this application and that the work to be..7E-rfoarmed will be done in accordance with.all SAN JOA,QUIH <br /> COUNTY Ordinaraee Codes,Standards,STA F•DLttp,L laws. <br /> ., <br /> APPLICANT'S SMG DATE. le /,� D,S <br /> PROVERI-Y/BU51NE5S OWNFI'iA O OR/I4ANAU6,1K C� OT'Nr'at AUT14Oxi7,ED AGENT zoLk_i �-t-- <br /> IfAI"PLICAN]is not rhe ILL1N -PAAR7y proof of authorizah'oa to Sign is require Ti rte <br /> k . „ AUTHORJZATION TO RELEASE INFORMATION- When applicable, I, the owner Or operator of the pi operty located at the <br /> a6o�e site address,Thereby auzlaorite-the release -of anyanzd all`resialts:geotechnical data'artdlo enviiorimeiital/siie`assessment <br /> information to the SAN JOAQUIN COUNTY ENvmoNmFNTAL HE.ALTA DEYI.R I'MENT as soon as it is available and at the same time it is <br /> IY <br /> I provided to me of my representative. <br /> TYRE of SERVICE REQuE§TED: _ <br /> COMMEiITS. / � <br /> R C IV D <br /> �. -./may/� ���� <br /> A .oto 2005 <br /> SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMpI.0 NEE = DATE: <br /> �! ! <br /> t: ASSIGNEDTO: EMPLOYEE DATE: it <br /> IAf <br /> Date Service Completed (if already cgrnpleted�: SERVICE CODE: 2 <br /> Fee Amount: l a� Amount Paid Pa ment Date <br /> x <br /> Payment Type ✓ Invoice it Check� 4C)`c� Received By: N <br /> EHD 48-07-015 SR FORM(Golden Rod) <br /> �- REv45€01111712003 <br />