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NOV-9-2005 08:53P FROM:HOLIDAY INN WHLNUI i7cxaoloi� <br /> SAN JOAQLTIN CouNTY <br /> ENVIRONMENTAL <br /> REQUEST <br /> HEAL t,H DEt'ARTMENT <br /> SERVICE <br /> FACILITY IDN SERVICE REQUEST N <br /> Type Of Business or Property J . <br /> CNECK If BILLII aT AD09lgQ❑ <br /> OWNER 1 OPERATOR Joe and Lillian Machado <br /> a <br /> FAcIurf NAME Machado Property 95391 <br /> SITE ADORE S22261 Mountain House Parkway Trac <br /> '« p1nD' S. Manteca Road <br /> HOME or MAILING ADDRESS (If Different from aim Addmss) 24916 <br /> fnr N "r <br /> STATE CA zip 95337 <br /> CITY Manteca <br /> En. APNN LAND USE APPLICATONN <br /> PHOXENI209-06,0-08 Unassi ned <br /> (209)836-2035 505 DISTRICT LoeAnoN CODE <br /> e. . <br /> PRONE N2 <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK if ANG ADDRE&S® <br /> REQUESTOR ,Joseph Riven! En. <br /> PRONE N <br /> 21 3 5-0005 <br /> BU&INESS NAME <br /> Global Invest ant & Develo met FAzN <br /> HOME Or MAILING ADDRESS ( 1 )3 - 405 <br /> I ee vee 1 O STATE f.A v° 90010 <br /> CITY Los An eles <br /> Bh t ThG ACENT: 1, the undersigned property or business owner, operator or authorized agent or some. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ,STAT nd FEDERAL laws. �o V <br /> 1 / <br /> ' DATE: IL <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSMEBS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ rifle <br /> If APPLICANT is not the EILL/NO PAM proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operatoany and all r of the property located at the <br /> ent <br /> informationatodthesSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHTDEPAR geotechnical <br /> has lsoon as itis available and at the environmental/site <br /> is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: YM'ENI <br /> COMMENT&: �V RECEIVED <br /> o' ul,- ✓ �.� (1v <br /> NOV 9 2005 <br /> SAN JOAQUIN COUNTY <br /> EMPLOYEE N: �� <br /> APPROVED BY: <br /> EMPLOYEE N: DATE:(( Lr 1 <br /> A&SIONED TO: <br /> SERVICE CODE: <br /> Date ServlCS,Completed (N slmady completed): <br /> FSS Amount: Amount Paid \ , Ov Payment OM <br /> Payment Type ✓ <br /> Involcs N Check$ 9, Received By: <br /> SERVICE REQUEST FORM <br /> EHD 46-01.025 <br /> REVISED 0-5-02 <br />