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jUN-04-2007(MON) 16: 03 Pilot Design (FRX)865 450 2840 P. 002/002 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of BuslnesS or Property � FACILITY IU# SERVICE REQUpEST 9 1 <br /> TndlGS 'a] l—yeJ f'1�� krj , 5 cis' K7J <br /> OWNER/OPERATORpi `rav01 l _n4er� L-(-C.-( /. CNecKIf uNOAoonCae❑ <br /> FACIUTYNAME i lo+ 7'rplvgl Ce �cY zh�- 1 11- <br /> s10 9� al,.t S 17`45L Qnr IZOQ C.� 1{ 777-! �G� G' ZIR -d- <br /> HOME or MAILING ADq�Q (�DlHoront from Sltn AddmaP l ft(ll�f Ui 1 <br /> CITY {%10 k U i STATE M <br /> PHONE#1U,W O Use APPLICATION#I�t•/' �b �S <br /> (8&5)588 WS �7 APN#�93.33n~ 30 <br /> PHCNEt2 EOD Durrmirr ' LOCATION OC <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES70R �iy��e 4( ,�e <br /> �rnV„ us PHONE <br /> �)aJCA9dHE�7CK If!BH�,LINOYp6bA�O <br /> D <br /> Res ❑ <br /> BUSINE9a NAME 1v) l � L <br /> HoMEorMAILNoADORM —5-" Dib aaJn <br /> CTY VIO J e <br /> STATE LP 367101 <br /> RII.IJNG ACKNOWLEDGEM F,NT; I, the undersigned property or business owner, operAtor Or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVMONMtNTAL HEALTH DGPARTMI?NT hourly charges associalcd with this project <br /> or activity will be billed to me or my business as idcatiGed on this form. <br /> 1 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 Caddy,Standardv,STATE nd FEDy a s. <br /> APPLICANT'S SIGNATURE: l /f DATe: 5� 4 0 <br /> Yaor6mvlsusLn'sss Ownatt❑ OR/ ANAGIUL ❑ OTHERAtM701 d7zn AreNr t YY��E�c�� <br /> tfAPPVC4JVT(e nar the u proofofauthorizatlon to sign Is required Val <br /> r <br /> A(ITROR17,ATIONTOIRF,I,F.ASETNEORNtATION: When applicable,t,the owner or uperator of the property located at the <br /> above site address, hereby authorize the release of any and all results, Seetechnieal data and/or environmental/site asscaamcnt <br /> information to the SAN JOAQUIN COUNTY FNVWONMENTAL HL'ALTH DEPARTMENT as anon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPEOF SERVICE REgUESTED: <br /> COMMENTS: <br /> L////o�(,(�o P... • ^� � sou r�•< JUN 0 4 2001 <br /> �NSA4R NMATetvW <br /> ACCEPTED BY: H EMPLOYEE#: ATE: <br /> AssiCNEDTO: U EMPLOYEE#: O S DATE? <br /> Data Service Completed (If almady completed): SERVICECADE: 2 P 1 E <br /> Foo Amount Amount Paid Payment Data <br /> Paymont Typo Invoilc,e# CChh/o'ck# Rocolvod By. <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111 7 2 0 0 3 Gfl �- <br /> WC w tri p. � 6AVA'7 , <br />