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SAN JOA( ,N COUNTY ENVIRONMENTAL I-IEALTIMEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bucinoss or Property FACILITY ID 0 SERVICE REQUEST N <br /> come c._ 5900 34- 5-7-7 <br /> OWNER 1 OPERATOR <br /> M our CHECK II B ILLINOADORE88� <br /> FAcam NAME <br /> R ✓ Z, g.OA 'T-5 i-DR/4 � <br /> SITE ADDRESS 5 S lnAeAR774U'� <br /> r ✓` atr .l NOmao ellen Slr Ni r CI 1 <br /> Orle <br /> HOME or MAILIND ADDRESS (I(Different from Site Address) <br /> 81 INumx r Slre el N.m <br /> CITY STATE LP <br /> PHONE el EXT. ADN 10 LAND USE APPLICATION 0 <br /> ( SI()) 3793 - 1:5-77 (-A - 0 -3 - 0 3 SA) <br /> PNONEe2 Eir. DDS DISTRICT <br /> LOCATION Coo[ <br /> ) <br /> CONTRACTOR / SERVICE REQUI;STOR <br /> REQUESTOR T/ ) ,/ r <br /> ✓�� ��/ �S�G CHECKII BILLING AODN[38 <br /> BustuRss NAME C �fNE Ct21/SUL7-/1VL-? PNoxEa <br /> 14 O <br /> NOME or MAILING ADDRESS FAx M <br /> P. D , r3ok 3 94 c ) ( •zsg 6 <br /> CITVn STATE CA ZIP ��� <br /> I11LLIN1: ACI<NOWLADGEMENT: 1, the undersigned properly or business owner, operator or nutlmrizcd agent or sane, <br /> acknowledge (hut nil site and/or project apcclr1C P,NVIRONMENfALIICALTFI DCPARTMENI'holll'ly charges ussucialcd With this project Or <br /> activity will be billed to fire or my business a5 identified on this form. <br /> 1 also certify that I have prepared this application and Chit the work to be performed will be done in ncconlnncc Willi all SAN JOAQUIN <br /> COUNTY Ordinnac'e Codes,Stemd rrdr, ST i and PLD 7 ws. <br /> APPLICANT'S SIGNATURE: DATE: -7 <br /> ' /7- C7 3 <br /> 1'110i'vilTYI III INI NKCN OWN Fit❑ OPEUATOl1/MANACRIL LJ Titan ADTII0ItMF..D ACY.N'61r / <br /> 1).A1'1'1.1E'AN'7-iS11e1the 01Lf.1Nrr/'JNMpronf PfINIIIIPrI•.nflell to a'1,QII ia'regldrtr( Nd• <br /> AUTIFORIZATION TO RRLRASIt INFORMATION: Whcn applicable, 1, 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 environmcnml/site assessment <br /> infOnniniOh 10 Ilse SAN JOAQUIN C0111,11'Y r-'NVIIIONMrN'1AL 1-I12AI.III DEPAIl'Ib i-wr as soon a5 it is DYuitable ball at the Same finis It IS <br /> provided ro me or my representative, <br /> TYPE OF SERMCE REOVESTED: iV/ TRAT'E LOA'D1N SO/L-Sll1'rA13I1 / 5rc,(0 <br /> COMMENTS: R E CE)V C D <br /> JUL 17 200.-. <br /> E AN JOAO UIN CnUNTY <br /> PIIDLIC ir1Ltx SrrVICfS <br /> LNW^('N.'.!,MTAL 11FAII40IVISION <br /> APPROVED by: EMPLOYEE N: �� a1 - DATE: -7 —I7-I/1 <br /> ASSIONED TO: /dJ EMPLOYEE M ¢ DATE: '7-( -1 -0) <br /> T_1( -1 -0) <br /> Date$on'Ico Complete (If alreadyeompleled): SERVICE COOS: Z5 1 PIE: -?-bol <br /> Fee Amount, Amount Pald Payment Date 3 <br /> Payment Type ./ Invoice N Check N 17 Received ay: <br /> E-1-1041101-025 SERVICE REOVCST FORM <br /> nrVlRrn a.5.04 <br />