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will <br /> SFR.vXCE REQUEST • <br /> FACILITY 1D# SERVICE RfQIfEST# <br /> .. Ype of Business or Property <br /> �ri:tGe f \ ren C-J�- F— SR G <br /> l <br /> OWNER 1 OPERATOR s. CHECK if SILLINCi AD1Zt�S5 <br /> 4i�-O-P, �t� S <br /> FACAAYNAME-- <br /> �n `^�c+.C,[C a �t`� 6to <br /> CL <br /> $ITE ADDRESS <br /> 81014 1 Zia Code <br /> Cocdq} "0 � T�C-L' N <br /> S�Number Dire fan � i <br /> t-(• <br /> Ulm <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> �� street Numb Name <br /> STATE zip <br /> CITY <br /> PNONE#1 W- APN# LAND USE APPI.iG^VON# <br /> —J <br /> - - <br /> ESct' @t7 DtsIRICr LOCATION CODE_ <br /> PffCiR��2 <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REC 11ESTOR CHECK ifBILLINt�DMss <br /> Pi4osg# FAT. <br /> BuslNess NAME <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE Zip <br /> BILLING AC1KN0 LFDCC.EMEI : I, the undersigned property or business owner, operator or authorized agent of same <br /> acknowledge that 31i site and/or project specific ErIVlRONMENTAI.H-ALT14 DEPARTMkN r hourly charges associated with this project <br /> activity will be billed to me Or my business as identified on this fol= <br /> I also cer,,f that i have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQ11 <br /> COUNTY,Ordinan-ee Codes,Stand ards,S Ir an F i".42 A7.law <br /> APPLICANT'S SIGNATURE' DATE' <br /> r <br /> 7 <br /> PROPERTY/BUSINESS QVYN18Lt -- t-�— <br /> � AGF Q OTHMAtT HOR1ZEli AQENTIfAPPLtC.�N,T is not theNr�':aaa� Pref►,f Of aati OCIZiNiOn Ica sigh is required Title <br /> At)THQRIZAT1()N To RELEASy,INFORMATION: When applicable, I,the owner or operator of the prcipertp located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroxnnentallsite assessment <br /> information to the SAN JOAQUIN COUNTY r:&NVIIWNMENTAL HEAL r1l DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE MUESTED: RECEIVED <br /> APR 0 5 2006 <br /> ICE- <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Engpt fSYFE d o DATE: <br /> AssiGNED 70: F-MFLoYEE M DATE: <br /> Date Service Completed (if already completed): CODE: an P 7 E: Q . <br /> Fee Amount: Arnount Paid 9• D !� Paymen Clare <br /> LP2—Eent Type Invoice# Check# [ 0 Received By: <br /> EHD 48-02-025 :: :{taG)1 . <br /> REVISED 19117/2003 <br /> T4 �1il�Jra H1-Iki�H -Is11hi�Ydhlii?iTr1N� i3CT.7t"3t� eT:9T 900Z/EZ/E13 <br />