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0�t 13 200 4.:-45A o�4BAUMBACH &APIAHA INC MEN� aL_H>EA�, >ll�-Dfj�>A �-rrN0.--0297 P. 2 <br /> x..., <br /> .+."� ,+;' °S .s' :i�« ..• . �.e4;a. :+ y-.,t..k.+,w, ..�.�... �y-,ri.a .:` �p Fz':i asY. ,.?'-' 'L't"4, .� , Fr," a ,1 <br /> Sri RVICE'.REQUCST <br /> Type of Business or Property FACILITY ID# SERVICE,REQUEST# <br /> l= <br /> OWNER OPERATOR �-�/ �� <br />! �Ii�Gl16u1V7,7 '! 2)/til' /Frei" Cx�CxifHit�wG ADbFtEss <br /> I{ FA61LrfYNAf�I� �, - <br /> `5 <br /> -,rte y <br /> I51TE A-1) j gLioo 6 I cA ��Z � <br /> 1 <br /> e tion Street Name C' Z ode <br /> �i <br /> HOME or MAILING AMORT SS Of Different from Site Address) <br /> Zip <br /> CITY <br /> PHI#E ext, !APN# <br /> _ x�r " - <br /> 1 PHONE#�- --,��--_�-�- t:x'r. _ ;: _ --�..�—. � BOS�f)ts'r�tCT:-� �LOC�Q -CO <br /> OFF <br /> - - <br /> �, <br /> REQUES7oR CONTR.ACTOR 1 SERVZC'l REQiJESTOR <br /> �. CHECK if stit_tH� c AnoRess❑ <br /> k. §' BUSINESS NAME= `� l�CSsa PHONE# EXT. <br /> _ 7Mr <br /> Fax# <br /> �?-D •GAG/ �'a <br /> HOME or MAILING ADDRESS <br /> j <br /> t CITY -- STATE/J 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 ENvrRONMENTAI-HEALTH I'TFARTMENT hourly charges associated witb this project or <br /> activity will be billed to me or my business as identified on this form. <br /> E also certify that I bave prepared this application and that the work to be:)t'rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Srundaeds,STAB'^ F DEIZ AL laws. <br /> APPLICANT' <br /> SSl( (DATE. <br /> t'ROPEttVX/SU51>VESS 0►vPIER� tILLINQ <br /> OR!l�'�ANAGF,EZ � OTNF;H AV7�HORrz�U AGcNT <br /> 1ffI1'!'L1CAN ss not thePnRTY,proof of authorizat(oa to Sign is require Title <br /> s . AUTHORIZATION TO RELEASE INFORMATION_ When applicable, I, the owner or operator of the property located at the <br /> above—sftc addrr6s;-h6rieby`authorize-thd release of airy and all-results:geotechnical data-atldW en ronrnchtal/site'assessznentA <br /> infornlatiotl to the SA14 1OA,QU;N COUNTY ENVIRONMENTAL HEALT}i DF-P,1,;rNIEN't as soon,as it is available and at the same time it is <br /> provided to gaze or t13y representative_ _- <br /> TYPE OF SERV[cE REQUESTED: <br /> R C IVED <br /> COMMENTS. <br /> z005 <br /> SAN JOAQUIN COUNTY SIO ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Ennw.orl r #_ DATE: It t <br /> ASsIGII To: EMpi.OyEE = tJ�J' DATE: if <br /> :r Date Service Completed (if already completed): -- SERvtcECooE: XI J PIE: j <br /> Fee Amount: 41 ara Amount Paid $ �+ Payment Date <br /> Payment Type Invoice# Check# �D�`� Received By: N (� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REvi5EQ 11/17/2003 <br /> k <br />