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S RVICE REQUEST <br /> Type of Business or Property FACII-ITY ID SERVICE RE:QUErST# <br /> OWNER I OPMMTM GH ECX if BILLING AnORES <br /> FACIUTYNAM <br /> Ar►ptss CA t1 <br /> ?� v tSsL✓ '� '�P '1 I Leda <br /> Hoagor MSG. (if Different frog» Addre5CITY ME 5) <br /> zip <br /> APN# LAND use APFUCATION <br /> ta'N cv',5—,)- cam: C3 <br /> PRONE#2 W. SOS MSMCT Locarlohl <br /> an <br /> CONT CTOR/SERVICE"QUESTOR <br /> R£QUESTORz -3 C�� t�cx if EW L MG AonIss[] <br /> Cis <br /> HOW or AMurNG ss FAX# <br /> C \ � S t 1b 397 k `l �'`� <br /> STATE L-t\ ZIP 9 S <br /> RULING N AJCKN0WLEDGEMENT- 1, the tmdcrsigned property or business owner, operator or authorwtd agent of s:une, <br /> acknowledgc that all site and/or projcct specific FNVIRONMMrrAL HEALTH DEPARTh eq r hourly amrgcs associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I abo certify that 1 have prepared this application and that the work to be perfv=ed will be donc in accordance with all SAN JoAQWN <br /> COtl3`1'T3'Ordinance Codes,Sfwuiar#4TArfOZA.L AWS. <br /> "P11+G TIS r <br /> PRO,+►EIrryt.8y1s �o orae/MANAGER El OmERAlrMoAnMT C3 <br /> IfApParcxhT rsnot the BBff.L" proofsfanthvrkafiantosign&regnired �ttls <br /> AiU' C3P"ATIM TO&FLEASE UO)OR MA`.TION;When applicable,Y,the owner or operator of the property located at the <br /> above site address, baehy authorbe the release of any and all results, geotechnical data and/or environrnental/sitB assessmeut <br /> informa#ion to the SAN JOAQUIN COUNTY BNVMOIC MENTAL HEALm DEPAR'x'tvmENT as soon as it is available and at the same dumas-it is <br /> provided to me or my rVresentatirre- <br /> TYPE OF SERVICE REGUmED: <br /> C4IENxS= <br /> AccaPTED BY: EMPLo'Ya#: nDV <br /> DATE: <br /> ASSIGNED TO: Rupi oYEE#: (SATE:fate ServiceCompleted of already completed), SEa�nP 1 I-:Fee Amount; Amount Pais! late ZPayment Type Invoice# Received By-. G <br /> REVISED 1111712003 <br /> TA 7n1,1H H I-t; H -Tv i N';wNI NTj*W--1 RE lAt'917 Gq:Z T. 90OZ 1t77 I!B <br />