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Jou l-07-06 07:46A Kt^adza ,and Assoc 559 3 2190 1'• '- <br /> SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DEP <br /> ARThiE NT <br /> SERVICE REQUEST <br /> 7fypfl of Susinestt or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/O EPUITOR <br /> -- _-a A IJ 5p A!?%ea,o CWCIK i'f PI6LIG A WRE5113 <br /> FAcit.uTv KmE: <br /> Srrl'r�DEPI�,ESS �.C1i5Wd, <br /> HOW Or MA1LINGADDRESS (if Different from Site Address) ISID E. �t4��Tt7gt� J�dlrti. <br /> S N ram Name <br /> CITT `-' STATE Elie —r <br /> P HONE 01 Fan. APPI# LAND Uss APPLcATaoN a <br /> (Zo l 41,0-1-DwP <br /> Paom 02 nom. f30,^a tMBTI;'Gr LOC ODE <br /> _ <br /> 4-- <br /> CONTRACTOR/SERVICE REQUESTf_1R <br /> I�EQl1fESTQd� <br /> 6u-SIKESS HAKE Pmxa# --- Exr. <br /> HOME or MA uxo ADDRESS FAX 1 71 <br /> 91'6 W, 2 A A*T^ XJE. <br /> C:rY t 1l_C1 STATE zip <br /> -ILLING ACENT. 1, the undersiped property or business owner, operator or authenzed agent of some, <br /> acknowledge that all site and/or pmject specific ENVIRONMENTAL,HEALTH DEPARTMENT hourly charges associated with this pr)ject <br /> or 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 perfortned will be dose in accordance with all SAD'.IOAQUIN <br /> CouNrr Ordinances :odes,Standards, ATE and F,' EItAL laws. <br /> A.iPPL-30k]'dT'5flIGNATURE: �=- DATE:- <br /> PROPERTY 11E U6,,04EXF OWNER 0 OPERATOR/MANAGERE3 OTHER ATMORIZED <br /> If r(PPLPC4NT Lr not the BILLING PARTY proofof authorization to sign is regained Title <br /> AL_ LWffla& iii TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located of be <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOA QUIN COUNTY'ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available said atihe same tim,it is <br /> provided to me w.ny represen�.tative. ---�PA..Y..MENT <br /> n?E OF SEWCE REQUESTED: L:L. (.ra2.1�' � H C�����$�' <br /> CON ?11a: l7 /OJ c'6 ?j L .- lJ1.�_ t-�v!¢_ JUL - 7 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Ac aEPTED BY: EMPI..oYEE#: DATE: <br /> AS rIGNED TO.' � EmpLOYEE#: <br /> IDateSer4leeComplrated (Ifalroadycomplesfed): SeRvmcoov PlE: <br /> !"Teo Amount Vo Amcurrt Patd I$ 7_g"5:U�-D Payment Date '7171 D b <br /> Payment Type involc e# Cheek# D Z 3Received By: <br /> EHD 413-02-025 t'l T lc� �,IN �`� -r4l S � aR FORM((Gofdsnn Rad) <br /> REVISED 11117M.03 <br />