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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bustinim or Property FACILITY ID 8 / SERVICE REQUEST X <br /> S Ne�`I hsln� Foo Ijlll <br /> Spb `� 2 �i�� <br /> OWNER/OPERATOR ' - J <br /> US n 1 C-V-r 6\e u M Car �rC>Za �o►1 CHECK If B&UNGAMMMO <br /> FA( I NAME S •} ��� <br /> SrrE Moms �{gj4len�n Lone- L�cI_� �5Qga, <br /> DwacgStreet Neer Ce" <br /> HOME or WuuNG ADoREss (tf DWereM from She Addre �Q r>C h v C�rle�Cl B l ud , <br /> 5 Streetss) weed., STATE str..t ft � <br /> Cm 1- <br /> wC� if \ rk <br /> (1 Al 3 a� <br /> APN A IJIND USE APrucAnoN d <br /> ( a5► I�f qa , E�, Q53A 0 - �I <br /> PNow$2 Em <br /> Bas DISTRICT LocAmm Cam <br /> CONTRACTOR / SERVICE REQUESTOR <br /> ESTOR <br /> r\ �r-C�S CP4MK if Bs.� <br /> B N' PNONE>x x <br /> �le E <br /> 11'1 r0. i,.)n � S- BISb <br /> HOME or RIAtt FAx! <br /> Cm IQc er (55 ) <br /> r STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned prop" or business owner, operator or autberized <br /> acknowledge that all site and/or() I roect Specific I:NVIR()NMFNTAI HF_A1 TH Ment of sject <br /> DF.YARTMF.NT hcxtrly charges associated with this project <br /> or activity will he hilled to me or my business as identified on thi. loan. <br /> 1 also cmily that I have prepared this application and that the work to he performed will be done in accordance with all SAN JOAQUIN <br /> (ouvrY On*a pwe•Codev,Sumdorziv,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: k- A��,a S <br /> _ DATE: <br /> 11korER-n*/Btismmj OWNER OrmtA /MANAGER ❑ OTHEtt AI AGSM❑ <br /> /I.4PPLI('ANT i.%not the BILL/N(;PARTY Proof ofantborizagion to sign is need Title <br /> AUTHURAZATION TO RLIJASE INFORMATION. When applicable, 1, the owner or <br /> 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 1OAc)t;IN COUNTY ENVIRONMENTAL.HFAI TII DFPARTMFNT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TTOE OF SERVICE RE«evw: <br /> IC� <br /> P AGE\v� <br /> � 05 <br /> () N <br /> A�B1'. 1)• C%4\�faj`I Fit oYEE tt: DATE: 5PN�0 oNM N ECSC <br /> AastsltElD TO: v�R RSM <br /> FJIPLOrEE*: <br /> DATE: HEP <br /> Date Service Completed (if an-dy c—Piaftd): S—M"M COOS: <br /> Fee Amount: Amount Paid fp (� Payrrlartt Dale �j C7 <br /> Payment Type Invoice SCheck wed or.S <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Gilden Rod) <br />