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SAN JOAQT� COUNTY ENMRONMENTAL HEALTE,, , ARTMENT <br /> +� �r SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '3 ?5-? 3K00 5~- w0 <br /> ')MER/OPERATOR <br /> j FAcanrNrE¢T FaclNiq 04042 <br /> MmADiwss {bn <br /> iS <br /> HOME or ALUM aDDR€ss (If Ddfferent from Site Address) t^�r„n d �a^^ar1 <br /> +�(" �i -Roo,, 3EOOO sv.ae N .. streetName <br /> CITY S� D_ STATE ZIP <br /> f� <br /> PHONE { • AFN# I..AND 1188 APPLICATION# <br /> (24) 464 -SRI /31— 1940-01 <br /> PNONEN BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUE TOR <br /> L+r.'s .9 r 014ECK If BnLLINo Aotigess j <br /> PHONE Al �• <br /> BusrlaEss lWvr1E S6-ttc ^+k ly►C -�KJ66-t(a�O %b",- <br /> HOME or MAILING ADD RES•,S <br /> ( FAX 9 <br /> !�). #plc 104" <br /> Frrrry Q Ef�h� T TE ZIPg49S4 <br /> BnLm ACKAIQWLSDGEMENT: I, the uade rsigned property or business owner, operator or�_1aiized argent f same, <br /> atowledge that all site and/or project specsfic E NVIRONMBNTAL HEALTH DEPARTMENT hourly charges assocla w1 s project or <br /> detivity wail be billed to we 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 91 SAN JOAQUIN <br /> Comy Ordinance Codes,Standards,ST laws. <br /> APPLICANT'S SIGNATURE: f'� DATE: <br /> PItornTY/BtulNm Owm a 0 OPUATOR/MANAGER ❑ Orsaa Au•rHoai=v AcsxrJW P la? air T� <br /> If APPLICANT is not the B1LLlHGPiRTY proof of authortWon to sigir Is required rtrir <br /> AUTHORIZATION TO RELEASE IMEASATION: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 environnumtal/site assessment <br /> (rtformation to the SAN JOAQUIN COUNTY BNVIRONMSNTAL HEALTH DEPARTMENT as soon as it is available and at the same tirne it is <br /> provided to me or my representative. t <br /> TYPE OF SERVICE REQUESTS <br /> COUNOW.. REG <br /> NOV 2 4 2009 4Zccqo <br /> Z <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> ACCEPTED BY: bL�t CIE EMPLQYe.E M C)32-( DATE: !4 71 a <br /> ASSIGN=TO: L!3 Q Ir.) EMPLOYEE#: T� 6 DATE: O Z(D <br /> Date Service Completed (if already completed): SEIMECCDE: PIE: 2 30b <br /> I"Amount; 3 Amount Paid 3445 ,.^ Payment Date b 7 0T <br /> Payment Type ✓ Invoice# Check S 2-Z Received By: gr,-- <br /> 8F1D z-a25 SR FORM(Golden Rod) <br /> REVISED 11117I2M <br /> i raS`Kl 119 a, <br /> l� Ljd ti[a�'J•, £err^ u�ex <br />