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/2005 12: 16 4640136 ENVIRONMENTAL HEALJH PAGE 01 <br /> SAN JOAQUIN t..pUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> ID# SERVICE REQUEST# <br /> Int/ re- k 0 U se S <br /> OWNER/OPERATOR Se��rcQ.S CHECK if BILLNG ADDRESSO <br /> FACaIrr NAME ✓i ' /. L-- 6 �apr `70 <br /> SITEARES$_ 7 ?J�y1/yl�/^� WOE �j n ✓O(•t�u(✓( <br /> / — D &.� d- 73 7 �o <br /> Stre t Number Direct S eet N <br /> HOME 0�MIADD�S (If Different from Site Address) �(-'Q /"tpn� /✓�✓C� <br /> /%J / O17 91ra Numhar 5 'ft <br /> CITY STATE ZIP <br /> i mor, <br /> ENr. APN tl LAND USE APPLICATION If <br /> PHONE#1 <br /> (S/o) 66/-�fal3 20-23 7-e.-7 4' -Ali Lx� lq <br /> ECT BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTO ///' /— L //\� _ -„ ,�/^ CHECK if BILLMG ADDRE35O <br /> PHo�IE# <br /> BUSINESS NAME �(. J�� / ��G � r/ `7 <br /> jT� t l� PA%# <br /> HOME o�M91L2c ADDRESS ✓ �g 9—G.S6/3 <br /> G�JJ STATE ZIP <br /> CITY / sJ n .�r.-, <br /> BML11v ACKNOWLEDGF,MENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> P.NTAT.HGALTFTDEPARTMENT hourly charges associated with this Projector <br /> acknowledge that all site and/or project specific ENIVIRONM <br /> activity will be billed to me or my business as identified on this form. <br /> T also certify that 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,Standards,STAT7andFEnr.R� -2 g in-5— <br /> APPLICANT'S SIGNATURE: Y— <br /> DATE: <br /> r-T OTHER AUT' )RTZED AGENT❑ <br /> PROPERTYIRUSmrsS OWNER IJ OPERATORIINANACRR Title <br /> If APDL/CANT is nor the B.rr1 TN_� G�pro .f of authorization to sign is required <br /> AUTIIORi7ATION TO RELEASE INFORMATIUN: When applicable, 1, 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 cnv ronmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENvIRONM TAT,HEAL-m DEPARTMENT as soon as it.is available and at the same time if is <br /> provided to me or my representative.S��00 l cf— <br /> TYPE OF SERVICE REQUESTED: y)t , <br /> v L S LC �Z G C C Al <br /> COMMENTS: w <br /> (p�,ro+ O <br /> R <br /> R/ SPN.IOPC`U\pTIER M t3T <br /> EN OEPP <br /> EMPLOYEE#: 3 Z/ DA E: q Z-t OS <br /> ACCEPTED BY: v L I i,” ( 62+`F EMPLOYEE#: DATE: q -a- QS <br /> �L � <br /> ASSIGNED To: (��c: Iz-CTS S SERVICECODE: _� IS PIE' <br /> Date Service Completed (If already completed): Payment Date <br /> Fee Amount: (o &0 Amount Paid <br /> _ Check# Received By: <br /> Payment Type Invoice# <br /> SR FORM(Golden Rod) <br /> SHO 48-02-025 <br /> REVISED 11/17/2003 <br />