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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST -�a coo +,24- <br /> Type of Buekr or property FACILITY iD# SERVICE REQtlEST# <br /> OWNER l OPERATOR SCANNED <br /> MIL"NAME <br /> &M AWMM 9If N e(-2--rt+ (?-I Po, ) /zl)� . I—,Po„J R <br /> 111111mmi N1 <br /> How or Mums AWREN {it Dblilurnt from sibs Address) p•O �o7C I j4S <br /> now <br /> Crrr f2_1 Po r,J STATE C.-P� 1FILO t o <br /> PHONE lit APN lR LAW USE APPLICATION <br /> P"m 02 808DISTRICT Cane <br /> t ) Dq <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUES TOR <br /> A433y IZacca CHECKffM6M&N=0 <br /> BLS NAM PH �# ter. <br /> Li rro�r� ywv <br /> v3� <br /> HoaaeorWMaimADM= 4o-} w• OAS `Axa ) <br /> Cny +. OD l STATE ZAP <br /> 1, the undersigned property or badness owner, operstar or aaftoried agent of same, <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 badness as identified on this form. <br /> I 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 Orad m mce Codes,S'tamlards,STATE and FMJMAk laws. <br /> APPIJCANT►S SIGNATURE: DATE: <br /> Pumm v/ltara m owN=Er— or=ATOR/mAmG= E3 ormmAuTwwv=AGwr E3 <br /> If APPrdcAw!s,rattheStr.wyuPAR proof of dwMankAdmtosign6mpdred Title <br /> When applicable,)f,the owner or operator of the property locoGed at the <br /> above site address, hereby audxdze the release of airy and all results, geotechnical data and/or envnvnnx rrtsl/sft assessment <br /> information to the SAN JoAQu N COUNTY EwntoNmwrAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representsive. <br /> TYPE OF 8E mm REO F8 mi: 12CV1 Cw Su ILF/tGt= * SAJ3SuR-F ACC I VF in <br /> Coamrxra: Q, a ( *' 2913 <br /> d, IAN JOaOUIN counlTY <br /> En VEROMENTAL <br /> HEALTH DLPARTMENT <br /> Acct ft. r t` / DATE: - t <br /> Asw=wTo: r" ct�i 6V u L6 EYPLOIIEE DATE: <br /> IN"$envies Cow*"%" (ltalresa!►ooaipis`d): Seance Cope: 'r>f <br /> Fee Amount -1,5-0. Amount Paid �� Payroemt nabs <br /> Payrnerrt Type irrvaice# heck# /00_3 Rsasived By <br /> EM46-02-M SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />