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JAN JOAQUIN t-OUN IT EN V IRONMEN I AL MEAL'tH UEPAK I MEN I' <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID f# SERVICE REQUEST# <br /> SP,00 lo-7(41-1 <br /> OWNER I OPERATOR <br /> 'TONY Chl th?PE CigRU BILLING ArcRE$e <br /> FALRrIYNAME CW'ihPPE f-htt+'IIS rA1C . <br /> SITE ADDRESSZZ(p �. ' F'('1 Crff W A'y `i- f\RM/NtiTOrl Z 3 <br /> s—Number 1 Nechy <br /> HOME or MAILING ADDRESS (M Different from Sne Address) 51+191 $ TRN LEY R-0 <br /> Number <br /> CITY 5 TV C-*C-tv1-1 STATE CA ZIP 9S ZI) <br /> PHONE 91 ETT APN/ I-AND USE APPLIGATKm# <br /> ( 2011 `fel - 5 9 9I) <br /> PHDKE#2 ENT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A 138`, lZN",0 CW-CK if BLURG 13 <br /> BUSINESS NAME LIJLr OAK- GE.O F.NVIRONi'/'It'✓NTf1� PHOKE tI STT' <br /> zai 3 r y 03+Y <br /> HOME or MAILING ADDRESS 0-4 VJ G Pile- 5-r- FAx <br /> `f (2 N ) 3b`!- () <br /> Cm L oa I STATE CA 2JP cl S 240 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE and 8PR laws. <br /> APPLICANT S SIGNATURE: DATE: 702-71/3 <br /> PROPERTY/Rl1S1NE8S0WN OPERATOR/MANAGER OTHER AIrrnowizED AGENT❑ <br /> 1f,4Pl`1A'A.AT is not the BILLING PARTY proof of auiAoriZadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HFAI TH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me Or my representative. p <br /> TYPE OF SERv10E REQUESTED: (LCV ICW Soil. s L,)tTh 31 l-1 5'ND Y 4ECF/y <br /> CorErts: <br /> 101;X113 uti <br /> / L5,C / G,r Jovyy <br /> F*r <br /> ACCEPTED BY: EMPLOYEE If: DATE: <br /> ASSIGNED TO: Cj EMPLOYEE#: DATE: <br /> Matte Service Completed (N already completed): SERVICE CODE: ✓ 2 PIE'. <br /> Fee Amount: a U`•� Amount Pai - Z�i • OD Payment Date 7,j( /,3 <br /> Payment Type Invoice# Check 30°7'Z!�--7 By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />