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A <br /> UG <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL EN <br /> NTAL HEALTI[I DEPART T <br /> NVI4 2006 <br /> SERVICE REQUESTNVIR �ENt <br /> TypeofBuslnessorProperty FACILITYiD* SER j Iq <br /> ES <br /> OWNER I OPERATOR <br /> CNZcKifBruaroAnom *13 <br /> FAcaanr NAvE <br /> 4k- Z t � <br /> eNo �W- q ] 207 <br /> HONE Or MAItlNt3 At)tNtESB (if OflfaneM from Sive Add►eas) Zb C <br /> anent �, <br /> CrTy STATE Zip <br /> PMNE91 APtU S tAroa Use AvPucaTmN# <br /> PKWE02 F=• VSOS Da mcT <br /> ( � LocwT+oN Cane <br /> CONTRACTOR 1 SERVICE R.EQUESTOR <br /> REQUE$TOR <br /> CHEcx tf BicuNGAmREas❑ <br /> BusiNESs NAME ppa En. <br /> HOME or NIAtuNG ADDRESt3 FAX# <br /> STATE <br /> RILtMG ACKNOWL T: I. the undersigned proPertY or budum owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVMONWNTAL HEALTH DEPARTMENT hourly charges associated wid'r this project <br /> or 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 acwrdance with all SAr.*IOAQU:N <br /> COUNTY Ordinance Codes,Standanls,STA lbws_ <br /> APPLICANT'S SIGNATURE' '> DATE: 7 /".� 06, <br /> PROPEaTY/BUSIMESS OwnEREI OPERA"W 01MM AUTBORtZED AG6svT - <br /> ffAPPGIGtNT is not the&LtLNGPet3Y proofofarNearF 4d0a ra sign is regaired Time <br /> AUTHORIZATION TO RELEASE INl QRMAM0Ne 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 environtnental/site assessment <br /> information to the SAN JoAQurx COUNTY ENVIRONMENTAL HEALTH DEPARTMENT NT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERvtcE REQttESTED: RECEIVE C <br /> ctn"WS: <br /> AUG 0 4 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Accepm BY: EntPLOYEE# <br /> Dare: <br /> AssiaNeD To: EMatov>:a#: <br /> DATE: <br /> Date Sw*e GWplgW (if alnsatry compkftd): St Rvtcts CooE PIE: <br /> Fee Amount: Amount Paid l� _ Payment Date y <br /> Payment Type ✓ Involoe* Chrck# Z 121 Rsoeitr8d By <br /> REVISE iD 1 Trim D � �C�N/ SR FORM(Golden Rod) <br />