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AUG -28-2007 11:19 RM Den•,isJones 2093341593 <br />P.01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID 0 SERVICE REQUEST # <br />OWNER/OPERATOR CAWK if =I& 0 <br />FacanYNAmE �r <br />SITE ADDRD88 � I La I 1t/n Yi',Ar�P �Y • (.A.iY I wVku <br />Noel Nam4pt_y �`_"tV7Vee� Mme <br />HONE or MAs.IRo AnnRE88 (Ir onlorent from Site Address) <br />abaN N a <br />CITY ._ STATE Zr <br />Prtwls <br />01 - .. a"• APN 0 LAND USE APPLICATION 0 <br />f I <br />pia IN - ear. 808 OteltucT LOCATION CODE <br />I <br />CONTRACTOR / SERVICE REQUEMUx <br />BD81wa NNAME i� � I Pit Dq _ <br />_- �'r�b�1 0�1 me �p <br />HONE or MAILING ADORE&' ,I, Iw A,. m. r. ,.. I Awo <br />Cot- STATE LP Q ( 5(A& <br />/_•Q' <br />gUlti.ttvr. AruN _VaL. CEhiEly_T: I, the undersigned property Or business owner, operator or aathorlmd agent of set e <br />acknowledge that ail site revJol prOjCCt, epecifle ENVIRONMENTAL HEALTii DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as Identified on this Corm. <br />I also certify that 1 have prepared this aRlk*IoFUd that the work to be performed will be done In accordance with all SAN JOAQUIN <br />COUNTY Ordinume Coda. iandan*, <br />APPLICANT'S SICNATURE: DATE: <br />PaorsmIllualwMOwwnl7 O R MANAC6R ❑ 0,rt=Aurumuz9DA0aNT <br />lfAPPLicnnT is not t P Pro <br />to b regwtred THU <br />T : When applicable, 1, the owner or operator of the property located at the <br />above site address, here;•y authorize the release of any and all results, geotechnical data and/or envirenmental/slte assessment <br />information to the SAN .Ia ,QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ae soon as it Is available and at the same time it is <br />provided to me or my mp xntstive. ,yk n <br />T^ ;x - — <br />,•. TIN JOA etMENT <br />ACCEPTED BY: <br />A891ONED TO: ot <br />Date service L76mpll <br />Fee Amount: $ t <br />Payment Type � d <br />CHO 48.02.026 <br />REVISED I I11T12000 <br />(N already wmpl9 W): <br />rp Amount Paid <br />r <br />invoices <br />ENPLOYEE #: <br />ENPLOYF.E#: <br />Payment Date <br />Check # �3 L J -' ` �-- <br />DATE: I -d-07 <br />DAre: ( .0 7 <br />PIIS: 303... <br />` 111 (o- <br />SR FORM (Golden Ran) <br />