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Work Order: 2254987 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILRY ID# SERVICE REQUEST/ <br /> LA,l v 5 <br /> OWNER I OPERATOR <br /> CHECK H SLUNG ADDRESS❑ <br /> FACRIrr NAME Lk L f yr, IK e' <br /> 1-(G <br /> SRE ADDRESS �S3 y r ./_h -,� ..•"rY GG� G3 c-J <br /> alnet NumMr DI X � `� J <br /> Coe <br /> HOME Or MAAING ADDRESS (N Dmerent from SRO Address) <br /> Strut X M. <br /> CITY STATE zip <br /> PN Eet Em' APN# LAND USE APPLKATNN)# <br /> PacwE 02 805049TRIcr LOCATION CODE <br /> I ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTO / <br /> { !K� �72_ CHECNRBILLING ADORESa� <br /> BUSINESS NAME Ear. <br /> 1 WW <br /> 3LtS'—�ZLt fe <br /> HOME or MAIDNG ADDRESS FAs 0 <br /> ? Ir (7011 'y-6'- <br /> CmLLVL� STATE G143 LP 'FgZ'LC0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMIo TAI.HEAIltll DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 /> COuN rY Ordinance(odes,S/nndardr,STATE.and PI:DERAI.laws. <br /> APPLICANT'S SIGNATURE: /jDA'rR::� ,,�-/�'/� <br /> PXOPIIR'rr/BIISINESSOWNER❑ OPERATOR/MANAGER❑ Dr11ERA1?IIORIY.EDACYNrf]I2 1/Pt'r <br /> !/APP1A'AM'is not/he BILLING YARN.Proof of allthoriZaden/o sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: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 results, geotechnical data and/or cnvironmentaYsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMRNII'AL Hi°.AI.m DI':1'AR'I'MENt SS soon as it is available and at the same time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REDUESrED: <br /> Coanwar3: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED rO: EMPLOYEE#: DATE: <br /> Data Service Completed (n aimady compiated): SERVES Coca: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Cheek# Received By: <br /> EHOAE-0 <br /> REV 11/1 SR FORM(Golden Rod) <br /> REVISED 11/1]2003 <br /> Tanknology Inc. 8501 N.MOPac Expressway, Suite 400, Austin,Texas 78759 <br />