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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTI&PARTMENT <br /> SERVICE REQUEST <br /> Type cN usiness or Property FACILITY ID I SERVICE REQUEST# <br /> SSG rr1tS.T70G �-Ocperro" FA-000395'4 52 0041 (,x7 <br /> OWNER/OPERATOR pAu M<-C-t,.J►•► <br /> 5--Se- (nuIAL— WOfZKs t`t LrMcZ <br /> POo� DSV. CHECK If BILLING ADDRESS <br /> Fr..E-g mP*JPt t�Eft <br /> FACILITY NAME <br /> 5C Pwe) - w© s fCaRPo�=wr�ro�s y�i�a <br /> SITE ADDRESS €. tA( -"A-To <br /> PSN <br /> Street Number Di ecHon Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> SbSF-P1A 1BACGLF CHECK If BILLING ADDRESS Er <br /> BUSINESS NAME PHONE# EXT. <br /> g pk&L,G p-Pa-rsi s -TXX-1 (2M 67-g-BW <br /> HOME or MAILING ADDRESS FAX# <br /> 2320 M A G6—xv C'-Ceecx- (74)q) 3G 7 54-24 <br /> CITY LOO S STATE CA <br /> ZIP q!� ,. <br /> BII.LING ACKNOWLEDGEMENT: L the undersigned properly or business owner, operator or authorized agent of same, <br /> ack-nos ledge that all site and/or project specific EN,,-IR0 NmENTAL HEAI TH DEPARTMENT hourly charges associated with this project <br /> or actin itv 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OI\'NER❑ OPERATOR/AIANAGER ❑ OTHER AirrHORIZEI)AGENT M--, C01JIxAL7/2 <br /> If_1PPLICA 7 is not the BILLINY,P RTF,proof of authorization to sigir is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable.I. the owner or operator of the property located at the <br /> above site address_ hereby' authorize the release of ani and all results, aeotechn' at data and/or environmental/site assessment <br /> information to the SAN JOAQUIN C-OLTNTY ENviRONi\IENT AL HEALTH I)IF11ARTNIENT as soon as It IS available and at the saine time It IS <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S r � �<� T FJAY1\,1ENT <br /> COMMENrs: <br /> MAR 2 5 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L I L `l EMPLOYEE#: 3 L-{ DATE: _� S G� <br /> ASSIGNED TO: L C-g o � EMPLOYEE#: �q � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j P I E. 3 .G,(? <br /> Fee Amount: C . 0 Amount Paid,7 — Payment Date — <br /> Payment Type <br /> Invoice# Check# 94 1 lieceived By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />