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08/09/2004 15:30 4540138 ENVINUNIVILN I AL HLAL I H I-'AUL 171 <br /> SAN JOAQUIN W NTY ENVIRONMENTAL IIEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 46 -57-47770k/ :: 1 /�- 5& 5 Zd <br /> OWNER/OPERATORCHECK If BILLING ADDRESS <br /> 8{� t0657- 1�045 i Pit vD i.CC�S L..L� <br /> FACUrrY NAME <br /> SITE ADDRESS 2q O.y n17 A 1400 T* -Da I vc— SZ�GL-T z)&f `>'S 20-7 <br /> Street Number I 0Ireetion rr Name --T— I ___m Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> strqkt Number 5 <br /> CITY STATE ZIP <br /> PHONE#9 <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT, SOS D►STRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if EmuNG ADDRESS❑ <br /> PAMCt-A YC--e465 <br /> PHONE# PAT' <br /> BUSINESSNAME -T-AI I 5Y576415 `114 5Z,7- 4-01) <br /> HOME or MAILING ADDRESS F & <br /> /f6 ,3 Jiro-ems <br /> CITY ©� ( STATE �r� ZIP qz k6!r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENWR.ONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will 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 JOAQUTN <br /> Cowry Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Z DAA' D- <br /> �v4)Ra . <br /> PROYEBTv/$USI1V6S,OWNER❑ OPERA R/MANAGER ❑ OTHER AL1TttORiZED AGENT P,�OG" Title <br /> Tf APPLICANT is not the B— LDVG PAR?Y Proof of authorization to sign is required <br /> a.rTTHORIZATIO TO 1tELEASE INFORMATION: When 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 ez�vironmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY FNVIRONMFNTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or,my representative. P T <br /> TYPE OF SERVICE REQUESTED: 0 T � <br /> COMMENTS: i I C �4k 7 E'�� �rL V i-(t� 1 Al y i7� 4t)'Mn LESS <br /> SANJOAQ�WRONMCOUNTY <br /> T H�EPAATMFN7' <br /> EMPLOYEE#: DATE: <br /> LJ <br /> ACCEPTED BY: <br /> EMPLOYEE#: -3 DATE: <br /> ASSIGNED TO: p E: <br /> SERVICE.CODE: <br /> Date Service Completed (if already completed): <br /> Amount Paid 7� — Pa <br /> Fee Amount: 0 _ <br /> Payment Type Invoice# <br /> Check# ( <br /> DR ? � 7� FORM(Golden Ro <br /> EMD 48-02.025 <br /> NLRViiT/SEqVICES <br />