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14:-LJ• ZUtI4b4U138 ENVIRONMENTAL HEALTH PAGE e1/t7w <br /> 4N .JVAO1 "-�VUN-I'Y L1YVlK()NiV EN'J.-A£,111EAL'A'11 1 11t'I-nt :\''i <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE 1tEGlUEST# <br /> OWNER I OPERATOR <br /> �►�-�"�.�) cri>rcx if aIL�G,aocRess <br /> FnuLm NAM2% <br /> SITE ADDRESS <br /> w" ire umber A'ro i e 5! ame CI Code <br /> HOME Or MAILING ADDRESS (It Di furent from Site Address) <br /> ^rt,;t Number Sfr Ma c <br /> CrrY SYATE Zip <br /> Nit <br /> PHONE 41 ENT. -7APN# LAND USE APPLICATION# <br /> PHoNz#2 Er. SOS DISTRICT LCCATIOHCADE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUrSTOR <br /> ! _ ,(1 CH=Kif. LINGAgoaE.M <br /> BUSINCSSNAME q �ynej--"`n.C'es � PHO <br /> G !C <br /> HOME or MAILINAD I$$ FAX# <br /> zx-* ('4M) C7 3.S7 <br /> CIN <br /> STATE CA, Z O 51�L -- <br /> Tf 71�fG A NQtiVI ED ?Vis I, the undersigned property or business Owner, operator ox authorized agent of same, <br /> acknowledge that all site ane/or project specific ENVIrRONMENTAL HEALT14 DEPAFTMBtYT hourly ehuges associated with this project or <br /> acti,,iity wilt be billed to me or my business 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 /> COINTY Ordinance Codes,Standords,S/3yE and RAI,laws- <br /> APPI.ICA ISSWNATURE: DAT-: _ �{ <br /> p'ROPERTY/BMSA`&sS Owlv>tx❑ OPERATOR 1 iU"kx xft ❑, 0'I'1mu AvrRoAlzim ACEIPr Id <br /> If 4PPtr ,tNT is not t!a¢ I,UEqt'a,proof ofauthnrf2alion Io sign is required Tine <br /> AMMR1ZL 0!TO RELEASE LJXQRIYT,-'I'IQN: Whoa applicable,1,the owner or operator of the property locaied at the <br /> abvve site sddress, hereby authorize the release Of any and all results, geotechnical dais an&or envirornxienfal/site assessment <br /> i-:forMation tO the SAN roaQUiN COUWry EirvM0NRUN7AL SIF,, LTH DS?APTMFNT as soots as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE orSERYicEREQUESTED: <br /> t-tc�t-a�-tc}r. t�t-.l�1-t uit.a� � �-��-.�c� ��:s u o re_+���r� Pry �cn Snrv-► <br /> �u S ec CPQ \A4�e !-BUST (Z.c),,, <br /> Prn.XJ ,due `T7ti� <C ti(r � C (� Fqr Q h' �i Fitt-►Ca C c E'tE° <br /> j NVCCAf) A-re- Com-(.lKe-Tp„ <br /> AccEPYsn BY: (_p�;E EuPLOYEEA: nC S DATE: e-) (f <br /> AsSlctJa n Yo: / 1 EMPLOYEE#: 7 C DATE: I ZIG'S� <br /> Date Service Completed (it aireadyeornpleted): srmcFCODE <br /> Fee Amount: Amount Paid �3�� U Payment Date Z <br /> Payment Typo Irvvlce# Check# p Received By; <br /> END 4"2-025 i <br /> REVISED 11117/2003 dl <br /> /��' , <br /> RECEIVED <br /> DEC - 5 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL_ <br /> HEALTH DEPARTMENT <br />