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r( <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F 100 <br /> 6WIME2CfAI— ; Sk00 q v SS 3 <br /> OWNER I OPERATOR <br /> IZ • WA4Tclz A II V'/Do cN <br /> FACILaYNAME ti — Coit/ GQ(�( n7EnI7- �. n r7 `' <br /> SITE ADDRESS /YIOSS Df}LE K� 4A 77VAO/ / r—.3I0 <br /> �a 9trest Ntmssr mwwftn <br /> HONE Or MAILING ADDRESS {N DRrorwn from 81t0 <br /> Address) <br /> p <br /> CITY 8bw1 Mumbai 9lmt Nmw <br /> I ^ STATE 7jP f3—Z3 0 <br /> PH01E#7 G—r^r E" APNI LAND USE APPDGAT*,A <br /> PNGNE1t2 Ev. BOS DIETmcT I.ocnnGN CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUES.'OR <br /> REQUESTOR Q <br /> O AJ7/r//�J!�� / CNECX H BALING A...,-.A...,-.ausmFsS NAME C�/ PHONES F=. d <br /> FsvE <br /> HONE Or MAruNG ADDRESS FAX# <br /> O 7q!/:� I <br /> CITY Lo STATE CA LP 5-3 <br /> 9 <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 ENVIRONMEITCAI,HLALTH DEPARTMENT hourly Charges associated with this project ` <br /> or activity will be billed to me or my business as identified on this`form. <br /> 1 also certify that l have prepared this applic ion and that c work to be performed will be done in accordance with all SAN JOAQu1N <br /> COUNTY Ordinance Codes,Srandardr,ST and FIDE ,yws. n - D <br /> APPLICANT'S SIGNATURE: DATE: �Z— 2 — O <br /> r <br /> PROP1RTY/BUSINESS OK'NER❑ OPERATOR[h UGER ❑ ea AvrnoRrcen AGPxr y, <br /> If APPLICAvr is nor the BrLL77VG P.gZZ proof of aurho rzadon to sign is required Tier, �V <br /> AUTHORIZATION TO RELEASE INFORMATION: When 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 environmental/site assessment <br /> information 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. <br /> TYPE OF SERVICE REQUESTED: f em+i / A" 0=PJrF <br /> coeuEws: <br /> -31�/ k's�vv� c�//r w/ ow-� � DEC - 2 2064 <br /> / _ may' 2;! SAN <br /> Ef M ONIM NTALOUN I h <br /> w / _ t ,?4 RL-PARTMEnIT <br /> ACCEPTED BY: EMPLOYEE 9: (j)Y DATE: rZ o <br /> ASSIGNEE TO: � EMPLOYEE#: frf L DATE: <br /> Date Service Completed (Il already complatod): Z3CL J� SERVICE CDOE: <br /> Fee Amount: ! Amount Paid �'�/�-- Payment Date <br /> -a �o <br /> Payment Type Invoice# Check# R melved By: <br /> FHD 4a-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />