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09/1$/2006 09:16 2094693433 EHLI PAGE 07 <br /> SAN JOAQUTAUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ip# —`� SERVICE REQUEST'# 7 <br /> OWNER <br /> e �1S�; �c �� FY�_0� 381S top �t� Z w <br /> P TOR <br /> US <br /> S 1p r(j �n CNSCKifBi�uNCAoonesSL�I <br /> F I NIM �S ----_-- <br /> SITE ADDRESS <br /> -'),503smwNYmea Loel I Poe. _ LCA I � <br /> StraBt N mo <br /> HO E or MAILING ADDRESS (if Different from Site Address) 1.11 I code <br /> 5 F�nbid . <br /> Cil _— S4av1 ame <br /> ew r r �Lr K S zip <br /> PHONE 91 Ezr— flow,t _ <br /> �1 ---ll PNo# LANOUSEAppucAroN# <br /> P�#2 j _ tYC� Err. <br /> I ) — '-- --- 803 AISTRIC7 ^ / LOCA T� a <br /> _ CONTRA_CTOR / SERVICE REQUESTOR <br /> R UEST R A . <br /> � r(,� Cneclo`.HILLIN OORESSI.�I� <br /> USINES A 1 <br /> S ,d 1 1�{ ��t PHONE _ _ E%T. <br /> H mEorMAI WoADgQRES FAxp <br /> 0.5 ar�ha �n '� I (5,Sj) 58l -_c tq q <br /> cITY1�l �= t�.r sT.TE Zip <br /> $ILIdNG ACKNO L EME1T: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail site and/or project specific ENviaONMENTAL HEALTH AEPARTMEVT hourly charges associated with this project <br /> or activity will be billed!o 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 ell S.4N JOAQUIN <br /> COLNTY Ordinance Codes,Standards, STATE and FEDERAL laws. �] <br /> APPLICANT'S SIGNATURE: ( � DATE: <br /> PROPERTR-/BUSINESS ONNER30' OPERATOR MANAAER C7 OTHER AwnioRl7ra AGENT CJ <br /> 'fAPPL(CANT]s not the BILLING PAR7y Proof at'authorizapon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORhIATTON: 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 environmentaVsite assessment <br /> information 10 the SAN JOAQUIN COUNTY E UIRONME <br /> provided to me or my representative. NTAL HF,ALTIt DFPARTivl6WTac SOOn a5 It i3 available And at the Same time 1[IS <br /> TYPE OF SERVICE REQUESTED. C.4_ 0.I I' ,�e171DATE: <br /> /�' �- 1, Q /J nc D {(tr��CoaNENTa: S Q/H,S�L �� 1,5D <br /> 1 006 <br /> cEPTED BY: — HEAUH <br /> EMPLUWEE#: 3 gp SE CES <br /> ASSIGNC•DTO: - MPLOYEE 0:I Date Service Completed (if at dywrnploted): SERv1ciCooe I g _] P <br /> n Fee ount: d� / crp Amount Paid Payment Date <br /> Payment Type Invoice#� Check# I Received By: <br /> EIiO 45.02.025 --�-- <br /> REVISED 11117/2003 SR FORM(Golde%Rod) :5' <br />