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FROG :B.Z.SERVICESTATION MAINTOCE FAX NO. :916 371 2540 isb. 23 2006 02:OePM P2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businm or Property. FACILITY ID# SERVICE REQUEST# <br /> 1 &Alen s o ) 9 2,_3 <br /> OWNER 10 PIERATOR <br /> n h cNMrtnNQ <br /> FAGLrry NAME <br /> -d' <br /> SITEAwa:Ess <br /> HomE or MAILING AoD se (m Different from Smo Address) J <br /> 8treel NumOer alr <br /> Crry STATE Tlp <br /> PNnNE#I E"*• APN a LA Use APPl1CAT to <br /> PHONE S2 806 Dl CT Locnmon cone <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> CMECKRFALUNO <br /> n <br /> BUSINESS NAME <br /> IHonE or MAtumo ADDRESSD' FAX0 ) <br /> 1/ 1 STATE 7F oL d„ <br /> BWLING ACKNgNn&RGEMNT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific FNVTRONMENTAL HEALTH DEPARTMENT hourly charges associated withthis project <br /> or activity will 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 all'ZAN JOAQUIN <br /> COUNTY Ordinance COdca,,Standard&, ATF and f'SDakAL laws. <br /> APPLICANT'S SIGNATURE: �� kr�I tII&&AbJ DATE: b <br /> ]PROPERTY1IkTgW1tN,40WNRRC] OPPRATDR/MANAGER❑ 6 <br /> IrAarucANTit not the 81714w3Paa.proofefautkmizodentosignisregmired trre <br /> AUTHORIZATION TQVJ,AM WORMATION: when applicable,I,the owner or operator of the property bnated at the <br /> above site address, hereby authorize the release of any and all results, geotechnicei data and/or enviroomentai/site assessment <br /> information to the SAN JOAQUIN COLINTY ENVIRONMENTAL IIEALml DLPAKIMEN'I As soon as it is available and at the vane time it is <br /> provided to ate or my reprcmatativc. <br /> TYPE of SERVICE RFMEMED: ECEIV ED <br /> conNIENrs: <br /> FEB 2 4 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Accomm BY: EMPLOYIM#: �iO DATR <br /> AastamEDTO: EMPLOYEE#: DATE: <br /> tIc _ fo <br /> Data Service Completed (R atnm*compkted): SWAM COW: PI�22Q& <br /> ,_," Z <br /> Fee Amount: U. Amount Paid �9-717— Payn'6 T Date �.� _Q(o_ <br /> Payment Type invoice 4 check# Read°Bd k; <br /> EHD 48-02-025 SR FORM(C,Olden Rod) <br /> REVISE 11/1712003 <br />