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May, 29, 2007 9:56RM � � No, 0491 P. 5 <br /> SAN JOAQUIN COCJNTY ENVIRONMENTAL IREALT14 DUARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# S VICE REQUE$7# <br /> Type of Business or Property <br /> 6,q5 577T/ 16 CHECKIf B tuN AD ES <br /> OWNER/OPERATOR CvN tl w, r� rp G T\C--" <br /> FACItITYNAME <br /> b),CTS ►`� <br /> Do V-0 <br /> SITE ADDRESS Ire <br /> CI G e <br /> Biro at Number DI eu <br /> Ne <br /> HOME or MAILING ADDRESS (If Different from Site Addre38) St et N e <br /> Sheet Number ZIP <br /> CITY <br /> NP # <br /> EXT, APN# '771 <br /> PHONE�1 I�I��G-i �SK/ <br /> ( } 90S LOCA-rION CODE <br /> PHONE 02 ETT. <br /> OR <br /> CONTRACTOR/SERVICE R.EOUEST <br /> CHECK if B i.uN A Rt: <br /> RBGIUZ=STOR `r 1�' (fi n 2— EXT. <br /> PHONE# <br /> BUS1NE58 NAME � .r?.( 1 <br /> FAX# <br /> HOME or MAILING ADDRESS ` ( X ) <br /> CA <br /> STATE � QIP <br /> CITY �C <br /> ILL ACI�NgVWLED FfV1 M 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMon this for ALTH DEpARTM1 NT hourly charges associated with this project <br /> or activity'will be billed to me or my business as identified <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA nd FEDERAL.laws- <br /> DATE: 2 <br /> APPLICANT'S SIGNATURE: OTstaR A�uTxoatzEn AGENT <br /> p>ROP&t1TY/I3U$tNES3 OtYNER <br /> ERATOR/MANAGER 13rifle <br /> If APPLICANT is not the BIGL"Vol <br /> .ARTY proof Of aRetlroYtzrrtiora to sign owner1,the rer/rrire <br /> A T OP.IZATION O EJELE SE INEOR Oan andnallresulse�geot ehn el datapandforte vironment 1/site of the property assessment <br /> above site address, hereby authorize the release of y SAY <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DhPAItTMENT as soon as it is available and at the some time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1 MAY 2 9 2007 <br /> COMMENTS: —;��PLCqt•`� /72) <br /> � J <br /> ,,rr�� -�j R'tpll�cc ,, lee .1.. SAN VIRON N COONI I '�' �/'(� / H�VIRONMENTAL•TY <br /> l_ I �U l�1-3� TH DEPARTMI <br /> EMPLOYEI:#: 0)//�- DATE: q L/ DATE: <br /> ACCEPTED BY. l�I�i f l -I tJ � (� <br /> EMPLOYEE#: <br /> ASSIGNED 70: SpRVICE CQ ODE: I q PIE: <br /> � <br /> Rate Service Completed (if already completed): Payment Date S In <br /> 'L`i �� S, (Pj <br /> Foe Amount: .7 3 g-s Amount Pald•0 0 Received 13y: <br /> Payment Type Involce# # b <br /> SR FORM(Golden Rod) <br /> EHD 40-02-025 <br /> REVISED 11/17/2003 <br />