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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMF.NT <br /> SERVICE REQUEST <br /> Type of Bualneas or Property FAOUW ID# <br /> SERVICE REQUEST y <br /> < :: ,�, <br /> CWNUR f OP�ERA_roft <br /> JISR-00 q UG-S- <br /> CWcK'f§&W0RAQMM13 <br /> FaatitY RAW <br /> ZG -7 6 <br /> ruc <br /> t®O _7 ��Tc_G��1 r��5 � IME or NAM AE Pin (W OWWO t hom Site Address) <br /> Shoot era <br /> Cm STATE Zip <br /> PMWE iii APN R L-0 o USE ApPuc^rm a <br /> F) 1-4) 2,1 7�, c�t l-4C�) <br /> PttoriE 02I SM0WMCT LocATion Com <br /> i <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REtwrsTOR -- <br /> F" l_.._L.`t C►+Ecx 1f Btt,ttNGAooREas C� <br /> ewe asNAMi —� ►'� t7 i PMWC En <br /> E ZC l ♦z r 4 CF=c cI- -2- - -'7 <br /> How or Maven o Amm" FAx a <br /> 1 - <br /> -2 ( Lr- c=7 —-Z -z- <br /> C.�TY STATE �^A <br /> I, the un dcrsigned Property or business owrser, operator or authorized agent of same, <br /> acknowledge that all Site andtor project Specific ENVIRON&MNTAL HEALTH DEPARTMENT hourly charges associated w0 this project <br /> or activity will be billed to me or any business as identified on this form. <br /> I also certify that I have prepared this appiicativn and that the work to be performed will be done in sceordsom with all SAN JOAQUrw <br /> COUNTY Ordinance Codes,Standards,STA laws. <br /> APPLICANT'S SIGNATURE:"�- " ? DATE: �� &I O <br /> PROPEL-TT I BUSINESS OwNrat❑ OPERA OTHER AUTHORIZzo AGENT �.- <br /> !fAPPLIGcn r is not thea LNG�Tr proofaf dwtlberirstion to sign is required rifle <br /> AUTHORIUMON TO RELEASE INFORMATION: When applicable, I, the owner or operator of the Property located at the <br /> above silt address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JoAQuN, COUNTY ENVIRONMENYAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OFBERVIGEREQUEaTED: C.GS�I�� <br /> Counnus: <br /> ��'P• ,��� �f `� ® S'C_��. 1'L-a SSS !�' �t u_S � �t�s "('i���v�D <br /> MAR 1 6 2006 <br /> `?�p�c� l�-nt��€ 'rvt3� �OP•S�c—�-r5 <br /> Acc <br /> lilv: <br /> mn <br /> � AN JOAOUIN COULN <br /> LCvEt(P„¢ Et�loree*: O3 L( LTl <br /> AttotcNEDro: Q-C FES EstPwYtittx: Pc{ 3 DATE: .-3 Ifo ®b <br /> Oats Sintrks Cort�tetad (tt altwalr oowplaaW)z srtnr+cE Cow: I P 1 E: 23.pp <br /> Fats Amount: -`j 9, tri Mteustt Pdd Payment Date <br /> TYPO ✓ 11MFW ae• Check# S Received By; <br /> END 4042-025 <br /> REVISED 11A TAM SR FORM((;older Rod) <br />