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i <br /> SAN JOAQUIN COUNTY ENvtRONMENTAL HEALTH DEPARTMENT i <br /> SERVICE REQUEST <br /> of Business or Property FACIIdfY ID# SERVICE REQUEST <br /> OWNER/OPERATOR CH&CXff9LUWL8M= <br /> FACWYNAW / J p 5 6 Cr®—?�r <br /> SRES ice,n 4 �Pv1�1�' I�.C� ( PGvt ri 5 3X16 <br /> HomE or MARINO AMES11 (V otnerant from site Address) <br /> STAVE Zit. j <br /> Cm <br /> >11 r APN# LAND Use APPLICATM e <br /> PHONE <br /> d ) <br /> #2 <br /> SAY. s0s =LWOOTION <br /> 1 i <br /> CONTRACTOR/SERVICE RJEQUE TOR <br /> REQUESTO CH9CK f ❑ <br /> 13UGME66 NAME <br /> PAx# <br /> FIOrrE or MARm ADDRESSgo <br /> CeTr L STA ZIP 'T' -7-Lj ' <br /> �tLLtNG ACKNOWLEWT: 1, the undersigned property or business owner, operator or authorized agent 0 sanme, <br /> acknowledge that all site and/or project specific ENVIRONMOTAI.fl1IAI.11i pp,PARTM1iNT hourly charges assaaietdd with this�project <br /> or activity will be billed to me or my business as Identified on this foam. <br /> I also certify that I heve prepared this application and that the work to be performed will be done in accordance with all SAN J6AQUIN <br /> C:()UNT'Y()tenunee(.'asks.Stundor&,STATS Red FrDSItAL laws. ' <br /> I <br /> APPLICANT'S SIGNATURE: � ���— ®A'tlt: <br /> I'uOrr.Rr►/ft61Y1Wrl�:tDWWNiR® OPERATOR/M!fi%G9R IJ Omm6aAtrnmoalr tpAGl 'la1 Ula <br /> (f AMrL1CRN7'lx not the Ql A P.t Z PF00f of authorization 10 sign is regalred <br /> A1LjCH IQ TO :When applicable,t,the owner or operator of the property I at the <br /> above sitz address, hereby authorize the release of-any a:td all Mulls,Scotechnieal data and/or environmental/site assgssmont <br /> inibrmation to the SAN JOAQUIN COUNTY F.NVIRONmFmTAL HaAt.w DKPARTMthtr as soon as it is available and at the same time it is <br /> provided to me or my roprosontative. <br /> TYPE OF SERVICE STS: <br /> COMM <br /> i <br /> ACCEPTED BY: EASSIOWD TO: <br /> EmPLOYSE#: <br /> Date Service Completed (#already completed): Soma CME: p i E. <br /> Foe Amount: Amount Paid Payment t7ate <br /> Payment Type Invoice# Check# Received 0y: <br /> EMO 48•02•025 SR FORM(04a Rodd <br /> REVISED 11117/203 <br /> S0/Z0 39Vd ASO-EhDihldl EbST99E60Z Sti:TT 0002/ET/90 <br />