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h <br /> SAN JOAQU*OUNTV ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CsQs�I;N� S S2p0 4C) z <br /> OWNERIOPERATOR I DECKNBUJNGADDRE5s❑ <br /> S �?eA-r'c Lim �r fLN ion <br /> FACILITY N MFS S t <br /> SITE ADDRESS <br /> a5o 0 Sa .. N ecoon 5tr..,Nam. <br /> Or^T ADDRESS (R Different from Site Address)—TOE"- <br /> ddress) �QYTGh� '�,ne�a ILII Jet. <br /> 05 _ s-eel N.m .r $tr..t N.nr <br /> STALE <br /> C ZJP 1 -,l <br /> rr� \ T1.CjY r k <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (<gc�5) gam Isa <br /> P"DE 1 2 E", <br /> Sr EMIG 09STRICT LOCATION CODE <br /> ISS ) 5 85- 8 15� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R!,!n ESQ R CNES <br /> ECKUBIWNDADDRS13 <br /> r S <br /> EXT.BpN ��-(�I2.tAm r i�1.Yl P 585- 815c� <br /> Br�E <br /> E or MAI05 ADDRESS d- 15541 585' c74`19 <br /> Crty STATE ZJP <br /> N��u r k <br /> RILLIN(] ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will he 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 JOAQUIN <br /> COUNTY Ordinance Codec,Standards,STATE and FEDERAL lawns. <br /> APPLICANT'S SIGNATURE:��rJ1QI clso�[ 11 DATE: <br /> PROPERTY/BUSINESS OWNER14 O►ERAT R/MANAGER ❑ OTHER AUTHORt7ED AGENT <br /> 1/APPLICANT is not the BILLINC PARTY proofofaNthorizarion to sign iv mquimd Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> provided to me or my representative. /l (�, ?� ry1 <br /> TYPE OF SERVICE REDDESTEo: S�- .P of atm �/I"'�^ `� c+ �6S- <br /> fiOaatTtls: 1Al13 SO S `�J>';^'--� '� S <br /> ojSD , 5 UVI TT�`"l' (,(ST 4'Txo�1 <br /> DEC 2 72004 <br /> SAN JOAQUIN <br /> ACCEPTEDBY: OLIO&1" EMPLOWh .L NTAL DATE: j421 O <br /> ASSIGNED TO: EMPLOYEE#: g J p DATE: ( 2'I( Oi <br /> EEAmount <br /> Completed (if airaedY competed): SBmceCDOE: <br /> 2�cI• J Paid ' Payment Date 1D IQ kft <br /> Payment Type Invoice# Cheek# <br /> EHD 48-02-025 �1_\ (fin Rod) <br /> REVISED 11/17/2003 \V <br />