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01/05/2005 13:11 2098382668 DIRK DYKXHOORN PAGE 02 <br /> t , <br /> SAN JOAQUIN CouNTX ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Blnineat or Property FACIL"10 N SERVICE REgUEST f <br /> A I Fav <br /> 5 26 I <br /> OWNER i OPERATOR C13CHECKN <br /> v <br /> FACILITY NAME '7� 1 1 1 <br /> SHE ADDRESS tr rrs'• �O ✓h KQ.. K7a;- e <br /> 90A went 1. P 96336 <br /> aft <br /> HonE or Mmim ADDRESS N E Ro—t eom sra Addrs"I <br /> O p r�o onrSul"NUMOW <br /> GTr <br /> ea/00y <br /> STATE IJP U <br /> PIIOIE�t FJ"- APNS LAND APPLICATION# / <br /> QICA) $3Q -2-4 $ C) -CSC` O �Y'�+ - O7G01 (oLl ALS <br /> PW*#Z E" BM DBnocTOC TM 006 <br /> (?09) 33f76V/ i s-— <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REciuEsTDR <br /> V k V t:MFat M BauNc Aowaess <br /> BusiNEw NAMEPNarE% Eu. <br /> orn 'Furan s <br /> HDME or MAIuw ADDRESS FAX# <br /> r S 1 1 <br /> CITY S C it/D N STA IJP —,3 Z <br /> BILLING AQ003JLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acimowledge that all site and/or project specific ENVJRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this farm. <br /> 1 also certify that I have prepared this application and that the work m be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: 1��r.[6 'U-7 <br /> PaovneTr/aus1NLe$OwNOI CI OPOIATOR/MANAGER OTmRADTMORmDACCNT❑ <br /> rf APPLJCANT i5 not the BILANG PART("proof of anrkaHzadon to sign Is required Titre <br /> ani]MORIZATTON TO RELEASE INFORMATION: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 envirotunemal/site assessment <br /> inf ykation 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. APNI <br /> TYPE OF Samm REDDMO: RECEIVE <br /> Dopar-WS: 1II Lrbl�� (i`e aP / `b`tej� NOV 2 6 2007 <br /> 11.13,t SAN JOAOUIN COUNTY <br /> 3� HFJUTH DEPAR M T <br /> ACCEPTED BY: C) L t�,ennc EMPLOYEF M ©�.Z. DATE: /I ui /O <br /> Aslatim D To: —1-A C EMPLOYE'#: l-F.D`ES DATE: (( 2-&(9 <br /> Data Service Complelad (R sweets eomplebd): SER'^p CODE: S'ZL PIE: -2-601 <br /> Fou Amaurlt: q(�. Amount Paid C� O Payment Gate 11 <br /> Payment Type ✓ Invoice N Chock* (D Received Br.f\[Cs <br /> Ergo 43m-025 SR FORM(Oaklen Rod) <br /> REVISED t I M 72003 <br />