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11/30/2010 17:24 2093675424 BAGLEY ENTERPRISES PAGE 02/02 <br /> SAN JoAQUw CO._e•_,ENvmoNmNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propaq FACIM ID# SERVICE REQUEST <br /> lxja <br /> OWNER/OPERATOR <br /> ► CHECK it MMAMS313 <br /> FACu n Y NAME m <br /> a °,, <br /> sir ss, ` t3 • floc. e1.r w.1- Gs�.�'�-*"a -�ce�,cln C�.Y•� `�S32t <br /> ------------- <br /> HoworlllmLwAmitm (M D from SIEo Add ) <br /> trout N r <br /> CITY STATE ZIP <br /> PwoNe#1 Eff. APN>r` LAND USE AppucAvoN 0 <br /> y - Ubtl <br /> FROW12 Em. SOS Do,K cT LocanoN Coon <br /> A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> euESTOR <br /> CHECK K SILhtNt'I��pORES9 <br /> OMMM NAME PHONES W. <br /> HomE or MAIuma ADDREii FAX# <br /> g <br /> C17Y a STATE C i ) ZIP <br /> MLLRLLG_ACKNOWLI MEMEN'1': I, the undersiped property or buginew owner, operator or aatbo J p <br /> 4aat of same, <br /> acknowledge that all site and/or proioct specific ENviR AL HEALTH DEPARTMENT hourly charges wsoeiawd with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done is accordance with all SAN JOAQUIN <br /> CoUNTY Ordinance Codes,Standmmds,STATE and FEDERAL laws, <br /> APPLICANrS SIGNATURE: )DAA; <br /> TY/13u Or ox/MANaGISIt Amt Ac1UNT C va+� +2 E�c��ca�.Tr y <br /> .{/APPLICANT is not the proof of amtkorkagon to sign Is required Trrlg <br /> 1tiZATION TO. )Ir RMA ;when appNcabl®,I,the ower or operator of the properly i the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirot►m,eotal/81 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTwIENT as soon as It is available and at the e a <br /> provided to me or my representative. V <br /> TYPE oFSERv= EsTEw. !1 - S " n ' SaN✓�qRU ,Q <br /> Si c�,Ll. new vw, Ses�sc�r v ei rvngv— In cQ'e�ga4,l TW k4 qVIV q L <br /> ®vr�� �'p 1�e, .bc�e� ea�:r► a.v,.r��L, M��`tea r mi <br /> c� <br /> � Q <br /> ACCE 13Y: Em ovae#: -��-� DATE.✓/� �.p <br /> Assn® i EmmoyEE#: /�� / DATE: <br /> ®at®Service Completed (if air Completed): SmrncaCODE: P/E:f� Qdp <br /> Foe Amount: �� Amount Paid Pa nt Data l t ` a <br /> Payment Type ✓ Invoice x Chock# —"k Received By: h'-t.5— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2M <br />