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.cru.avn4.vu.a.v�n� l LIRY1RV1WYfP.1�1lTL11G[1LlR1lGrlll�lDrGi•l <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S Kao �- 7 �_4 , <br /> OWNER OPERATOR �-y <br /> N c,N CtEot H @ILUNG ADDRESS <br /> FAa ffNAME �oi'rNSaw FR-RZIEiZ R-RNC.H <br /> SITE ADDRESS 22240 E <br /> Sheet Number I Dbecdm Sbeet Name <br /> HOME Or MAILING ADDRESS (If Different from Sfte Address) 2 Cn) & W Yh{N�"T t.ti= t • ? <br /> Street Number <br /> CITY 5-ra pori STATE LAP% ZIP Gi -zo`{ <br /> PHONE#1 APH8 O#Oi;-- Z20- O'3 LAND LIM APPLa:AT10M= <br /> ( zo1 ) 4p2 3lsp oors- -z- oma Pf•- Lzoo7-30 <br /> PHONE#2 gT- BIDS DISTRICT LOCATION CODE <br /> 16 04Z 1 C G <br /> CONTRACPOR J SERVICE REQUESI70R <br /> REQUESTOR AlaB4 (2ACco CwcK N t3atm AaDNESS❑ <br /> BUSINESS NAME PHONE III �' <br /> HUE o/tlL GEOE bJV1RonA'vF-^ TR L- zo9 <br /> HOME Or MAILING ADDRESS 4, -,, v.J. OA'W ST. FAa# D3 •� <br /> ( 109) <br /> CITY troth - STATE CA ZIP <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or budwss owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DPPARrmFNT 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 bane in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and Flat laws. <br /> APPLICANTS SIGNATIIRE: ` _ DATE: <br /> PROPERTY/BUSP7FSs OWNER❑ OPERATOR/MANAGER ❑ O IHER AurnoR®AGENr❑ <br /> ff AVPLTt:ANT ix not the B LjxwY.PARTY.proof of euaWr&adbn m sign is required Title <br /> AUTHORIZATION TO RELEASE INFORA9ATION: When applicable, L the uwner or operator of the pruprity located at the <br /> above site address, hereby authorize the release of any and all results. geotechnical data and/or environmentalAite assessment <br /> inforTnation to the SAN JOAQUIN COUNTY EN-VIRo N.ME'TTAL HcAmm DEPARTMT-rNT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PAYA ENT <br /> TYPE OFSERvxEREcuESTED: R vtt t Soil Su rr^VI u I-71, S svDy RECEIVED <br /> Comariffs: Io�w�t3 I//7i/13 JUN 18 2013 <br /> �CfL7 Y a IEU� l`t� ao � SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY. All EMPLOYEE#: Z & TO DATE 6 / <br /> ASSIGNED TO: - EMPLOYEE#: Cl KATIE: Ahi-/ ( 3 <br /> Date Service Complettad (if akeady comptrted): imvICE CEIM: 17 Z Z P P o ( <br /> ; Foe AmourRt: A;ount Paid 5Z -- Payment Date <br /> Payment Type ;,.- i Invoice# Check# �:/ Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />