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12DeC • 10. 20041!10 ;22NM?0946833 FIFTH FLOOR • No - 1247 P. 4;E 82 <br /> SAN JOAQUIN COUNTY I'NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Sualneea or propargi FACILITY 10# BERVIC!REQUEST p <br /> OWNERI p f1A OR <br /> FACILITY.HAME <br /> E'[i//J� CWGX IfJhhUNo AopReee❑ <br /> O4Cf7 oee/ S� L <br /> fflalvnRrss pf;vLon M4C)1� d � - A?0JClrp Cad, <br /> ftUMLI NGMORRO$ (if Dfffannt from Sits Address) <br /> STATE zip <br /> (.Ot)9I c APN A LANu Use APPLICATION M <br /> HONG p1 �33 ' 7, o ea. <br /> PHONE92 r-� aT• BOS 01G=cT LOCATION QOOe <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuesrole r�7�qr�1 <br /> CHECK If7�;t <br /> f0� <br /> BUSINassNAME , PHONe#N N - n/ rI �6-JHOME or AILING DDRISS FAX#� �(1 bb6 6 <br /> CITY 1R W.tJ y/V STATE Wq 7.IP <br /> BILLING ACKNQ GEMENT I, the undersigned properlyor business owner, operator Or 811thorized spot of same, <br /> acknowledge chat all site and/or project specific ENVIRONMENTAL I4RALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 121$0 certify that 1 have prepared this application and that the work to be performed will be done In accordance with all SAN JOAQtiIN <br /> COUNTY Ordinance Codes,Sra, a SrA"+L laws. <br /> APPLICANrsSIGNATUREty��_� y DA1'16I �� �U f✓y <br /> PROMRTY/BUSMESSOWNER❑ OPERATOR/MANACA'rt [] OTa6RAUMOAMFOAGENT � op �^ <br /> {fAPralL•i7A7'Is na!lha ArLLlNO Pnerr proofgfrrarhorlSxltFdn ro sgrrbr¢grelred' reet <br /> AUTHORi.�„ATIIYN TO RE!'!'o,E INFORMATION= When applicable, I,the owner or operator of the property located at the <br /> above efts address, hereby authorize the release of any and all results, SdOteohnioal data and/or environmental/mite assessment <br /> in'fOmU#iOn to the SAN JOAQUIN COUNTY ENVIRONMENTAL aALTH DWAR'TmzNT as soon as it is available and at the same time it is <br /> provided to me or my ropresentative. <br /> TYPE OPGRIVICEREQUESTED; —V"� Jp�_ <br /> COMMENTS: <br /> AOCeFTRO Etvt EMPIAYaa#: <br /> G DATE! /Z <br /> ASSIGNED TO: ,(�e -� EMPLOYEE#: 2-251 1 DAM <br /> Date Serriee oomplsfed (M efraatly COmplatad): comae OmniL4pf g / <br /> FeeAmOunt: .I 1t Sim Amount Paid 18.• PaymaittDate IZ to 04 `� <br /> payment Type !nV»lee# shook# <br /> Roos d py: <br /> EHOREV SED 11/1 SR FORM(Golden Rad) <br /> REVISED 11/1 TI20n3 <br />