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anN�a�antiurry�,V UN IT L'IN V IKUNMEN'I'AL nLAjwtl IJEPAICI MEN <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR A16ELA ; JA-wtE.S L,gv><GUE <br /> CHECK if BIL 1 DURESS <br /> FAGLRY WAME \.AYE,LLE P Rv PE.1�-r <br /> SITE ADDRESS 32-S <br /> How or MAILING ADDRESS (re Different from Site Address) <br /> C e CJrQI. NJAa/AR.�� roumbsrstma N <br /> am <br /> CITY Tey STATE zip <br /> PHDNE#1 ETT APN# LAND USE APPLICATION# <br /> (ul ) 83(0-00os- 71;5- loO-z(P II - 231 '�Us <br /> PHDNE#2 rXT. BOS DISTRICT LOCATION CAGE <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR A. � � <br /> �P <br /> CHECK N 8G.t.ING Aon© <br /> BUSINESS NAME Live 041OG_ PHONE# <br /> Ear. <br /> 201 13fn9-O`3'�S" <br /> HOME or MAILING ADDRESS N-{,O•} t.V. CMCJ S'T`_ rAx# <br /> CITY LG�t STATE CR ZapgS�,,�a <br /> BILLING AC[Q\OWLEDGEiNENT, 1, the undersigned property or business owner, operator or autborized agent of same, <br /> acknowledge that all site and/or project specific Fwv1RONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on Ibis:Form. <br /> 1 also cettih 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,Standards,STATS and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12 — g�orl <br /> PROPERTY/BV51NESSOWNER0 OPxRATOR I M.ANAGLR OTN6R AUTHORIZED AGENT© <br /> ffAPPLIC-"IT is nor t1V.BILLINC AIR Z2 Proof of authorization to xign it required Tule <br /> AUTHORIZATION 7Q RELEASE INFORMATION- W ben 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 environmental/site assessment <br /> information to the SAN J41AQUna COUNTY ENv1R0NMENTAt,HEALTH DriAHTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERmF REQUESTED: $UT3SVfZ.F/FCE C_oP-TNN1tPJPM0Npe{ --r <br /> COMaERrs: <br /> RECEIVED <br /> DEC 13 2011 <br /> SA/ J ROHM Y <br /> NTAL <br /> HEALTH DEl'AFtillEHr <br /> ACCEPTED BY; <br /> D L I V l=N 4!4 EMPLOYEE#: 0�Z( ZSy <br /> A$$IGNED TO. S l'O /1� `Q� EMPLOYEE#: C�Ot�Date Service Completed (N already completed): SERVICE CODE: 3Fee Amount: ZSc Amount Paid Z Payment DaPayment Type Invoice# Check# <br /> EHD 4M2.025 SR FORM(Golden Rod) <br /> REVdSED 11/17/2003 <br />