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09/07/2007 14:23 20946401'9 ENVIRONMENTAL HEALTH PAGE 02/02 <br /> ...... .,.,..K�. L.v4lIIA asre r 1M1VIe IY181V 1A1.,"ALAI- AAAXA14k k IVAL1V'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> pvL RG CZ \4 \N -7q. �-,g SZO// �7 <br /> OWNER OPERATOR �— CHECK if BRLINGADDre3s❑ <br /> Q,VNCTRFY VA\ LE Rv t \NC . <br /> F NAME <br /> SITE ADDRESS NAW s . AGN w Ry qq S10c\L-T0N glr.\U <br /> Slreer cumber Dlrp (iron Street Name cav 210 Cede <br /> HOME or MAILING ADDRESS (ifDifferent from Site Address) <br /> Ti�rr10 • I stmet Numb@r seeel Name <br /> 5R R 0 �A ATF �P S <br /> PHONE#t Q`1 APN# LAND USE APPLICATION I <br /> l79' — <br /> PHONE#2 BOSWSTRICT -2 LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CNECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE A EXT' <br /> HOME or MAILING ADDRESS FAX I <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: T, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL IIEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also terrify ibat I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard, STATE and FEDERAL laws. - <br /> APPLICANTIS SIGNATURE: 2•���, DATE: o4-lf-O 7 <br /> PROPERTY/SU ,CR SINROWNER 13OPF•R.ATOR/MANAGER 13OTnvu AvTNORizED AGENT 51/ <br /> IfAPPLJOINT is not rha 2?HLlN6PARTY proof of authorization to sign is required 'rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,T, the owner or operator of(be property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site Rsscssment <br /> information to the SAN JOAQUIN COUNTY ENvrRONMENTAL I{EALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: Cd'C A-)S Lt _f-7 O nj — /Vt, w? O�.0 NCi� PAY ENT <br /> COMMENTS: Crn <br /> SEP 9 2001 <br /> .SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE$: �� DATE: <br /> ASSIGNED TO: /7 ,.k,y I E z_ EMPLOYEE 9: L?S DATE. G/ l q ('07 <br /> Date Service Completed (if already completed): SERhOE CODE: C;6,r P 1 E:(C; L <br /> Fee Amount:_ o� Amount Paid 'A payment Date -) `C) p-1 <br /> Payment Type Invoice# Cheek# '�..{ i✓-, }� Receivyed By: <br /> EHD 48-02-025 `rSMtiMl.Cjil,B'�i"Cisitl).- ( <br /> REVISED 11/17/2003 <br />