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10/03/2007 09:45 U iN I X ZIN V IKUN MEIN I AL nhAL 1.VJ6Uh- rAR I AMIN 1 #0050 P.020 /021 <br />0 <br />,,A1-4 JVAk2LJA <br />SER VICERE, QUEST <br />Type of Business or Property <br />FACILITY ID # <br />FAf <br />SLCERVICE&REQPEST # <br />SLISINEss, NAME <br />T <br />PHONE 9 Ext. <br />ACCEPTED BY: 0 Cr I f <br />OWNER / OPERATOR V <br />Empt.oyn <br />CHECK if BELLING ADDRESS <br />S (A— <br />FAx # <br />CITY <br />FAcIUTy NME <br />r-, PHI) bir- DRA <br />ed I <br />.<kSITE <br />DATE: (,o <br />ADDRESS <br />_Fst-RVIC9 <br />J LT01,-52-q2- <br />Street Name <br />Fee Amount: 2-"- et-) <br />HOME or A4hI.1-NG ADDRESS (if Different from Site Address) <br />*A I-A- <br />(;"F— <br />Payment Date <br />`0) 0 <br />--- <br />'d27,ZS r <br />64e -eft# <br />Street Name <br />CITY <br />STATE zip <br />2 -- <br />PHONE #1 Exr. <br />ILI 5 7 0 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />SO$ DISTRICT <br />LOCATION Cone <br />-- <br />. CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CO AJ,i c,t 0 <br />FAf <br />-A -2- CHECK if BILLING ADDRESS <br />SLISINEss, NAME <br />1,4, <br />PHONE 9 Ext. <br />ACCEPTED BY: 0 Cr I f <br />Empt.oyn <br />HOME or MAILING ADDRESS <br />S (A— <br />FAx # <br />CITY <br />y STATE zip <br />)91T,LWG, ACIC-NOWLEDGMNIENT: 1, the undcrsigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific FTrv9R0NM)ziN-rAi. HEALTi-i DFFARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <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, Srandarciz-, STATE an <br />yd laws, <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / Busir-mss OWNER 0 OPERATOR IMANAdER E9 OTfirn At.PTnoPj7xD AcENT <br />IfAPPLICINT to not the BIL/.(Ng PAETY, proo <br />f of authorization to signs is required Title <br />AUTHORIZATION TO RFLEASE INFORMATION: When applicable, L the owner or operator of the property located at the <br />above site address, hereby autbot'ize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN Coumy ENv1R0NM2NTAL HF-ALTI-I 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 REQuEsTF-D: �,S T- <br />CO AJ,i c,t 0 <br />IJ <br />PAYMFNI <br />Commws: <br />RECEIWED <br />Qp't- <br />SAN jOAC)UN C-0 QTY <br />HLAILTH DEPARTVIUNT <br />ACCEPTED BY: 0 Cr I f <br />Empt.oyn <br />DATE: io <br />ASSIGNED TO; C-,4- C-44' 1 7— <br />EMPLOYEE #: <br />/V Z,2, <br />DATE: (,o <br />Date Service Completed (if already completed): <br />_Fst-RVIC9 <br />CODE: 0 & <br />PIE: <br />Fee Amount: 2-"- et-) <br />Amount Paid <br />Payment Date <br />`0) 0 <br />Payment Type.f,,., C=2�e tgj Invoice # <br />64e -eft# <br />14 RL41 <br />A <br />Received lRy. Nit--, <br />— <br />C 0 V% <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />