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jun.09.2010 10:32 AM 9 1 PAGE. 1/ 3 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE RI&QUEST <br /> Type of Spoiness or Property FACIL D SERVICE REQUEST# <br /> c4��b5� au <br /> OwNsR I Opr=PATOR <br /> i L:1n CHE41C n II�lwo Anon <br /> FACILITY NAME <br /> 3 1 VAC <br /> Sn Aoimss 3E, <br /> Stmt Numbor I Dlraalibn em <br /> HOME or MAILING Ames (If DHrerent from Site Address) <br /> Sbeot Number Street NAMS <br /> CITY STATE zip <br /> PHONE01 ExT• APN O LAND USE APPLICATION# <br /> ) — ZQ(� q <br /> PHONE aft EXT, uOS DISTRICT LQCATION CODE <br /> CONTRACTOR/SERVICE REQU.ESTOR <br /> REOMSTORCHECK if 111LUNQ 62P ,EI <br /> Sl1SR1E AM 11 PHOIff# Er'r. <br /> HoM r AD)REM FAX# )�� � CJ r <br /> l0 /c)S `t" <br /> CITY STATE zip <br /> .0 <br /> BIL II!.ACKNQ.y,V�I&gUVMEN : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVTRONMFNTAI,.HEALTH DEPARTMENT hourly charges associated with this project <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 performed will be done in accordance with all SAN JoAQU1N <br /> COUNTY Ordinance Codes,Standar '\\rA t-H and IF... L Iaws, j <br /> APPLICANT'S SiGNATMIE; U -I-- L� UJ UATL: <br /> PROPERTY/BUSINESS OWNER 0 ()ri1:RAr0XIMANACTICR L.A OT119RAUT1I0RIZEuA(;FNT11 <br /> /fAppmc;Ami,is not the Rr[Llb!g�pmf of 4u1h0ri'x0tl0n to sign Is required Title <br /> A]QTHORIZATION TO RELCA5E INF RN1' TI N: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all rusuits, geotechnical data and/or environmental/site assessment <br /> infotmati©n to the SAN JOAQUIN COUNTY ENVIRONMEN1:AL HL•:ALTH DEPAICIM;N 1 as soon as it i5 available and at the Same time it is <br /> provided to me or my reprCsentativc. .�n <br /> TYPE OF SERVICE REQUEWFD: LA. 1 { ! -L1 F t� <br /> COMMOM:To- . �U.Ca > �/-s r,�-��'"�r GAJ S C{ S <br /> ,�'J� REQ ANT <br /> P!� G `7� l y�p <br /> JUN 15 2010 <br /> SRN JOA <br /> ACCEPTED BY: t�-/� EMPLOYEE . { DATE: I DtrP <br /> Q�-I v�;, <br /> ASSIGNED T0: -/,(' EINPLoYEF M .L-Ci7! Lam. DATE: & (--1Zr tJ <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 4 3 4 e-.t,/0 Amount Paid 1. Payment pate 6 Ll S <br /> Payment Type Involce# Check# R+aceivt3t!By: <br /> EHD 48.02-025 SR FORM(Goloon Rod) <br /> REVISED 1111712003 J-- <br />