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03/10/2005 08: 51 2099£ 134 OFFICE PAGE 02 <br /> U3/UB/2005 14:00 FAX 209 9410M _ ti IM00`2 <br /> SAN JOAQunv�vtvTst ENVIRONMENTAL HEALTH DEPARTMENT ( ��7 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 0 SERVICE REQUEST# <br /> I-RucK PtwIA1b 'Lcir s2OO 4 /4 9 9 <br /> OWNER/ OPERATOR <br /> Davwk 5t Iva CNEGr1f131wNc ADDPrsa❑ <br /> FAOLFTYNAME I I vaTr t�C 1�'A, <br /> SrfE ADDkEss ([ <br /> O tJN�.ne D;ernow <br /> z <br /> HOME or MAILING Aorutm (ff Different from Site Address) a/l <br /> (� 56aetNu <br /> CITY />l C K- LOQ STATE q ZIP s <br /> PNONES1 (7TH T r°rT• APNil [AND USECA,PPUCAnoN III <br /> ( 067) q$ X43-iso - a� 7? 42� o <br /> PHONE 92 On, 608 DMMMMCT LocATIDN CODA <br /> A . <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR [1'-'''�� <br /> Fro� CND <br /> lCNI RLINa7ADDRe_411:.,I <br /> BUSINESS NAMEe', {/w /, PNONE ft • <br /> /I1.4 <br /> 01 9Y8 —/3'/S P 30 <br /> HOME or MAILING ADDRESS ^ ¢` t' FAX 4 <br /> ( 1769) 9yq — <br /> CITY S716Ckboll STATE `'A ZIP CjS� C <br /> 491:WQ AC—CX0-V I EDGEMENT: 1a the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific EN VEWNNCENTAL HEALTH DEPARTMENT hourly charges associated with this pro;ect er <br /> activity will be billed to me or my business as identified on this fOIIa <br /> I also certify that I hive prepared this application and that the work to be performed will be done in accordance with all SAN IOAQLJLN <br /> (MINTY Ordinance Codes,Srandards,S=r6*aP'LZL— <br /> APPLICANT'S SIGNATURE: DATE: �/10/m— <br /> PROPEkTY/BUSINFW Owmaa OPERATOR/MANA9EK ❑ Omits Auraotuzen Aciowr 13 ©04,0 <br /> Tf iPPr✓�ts nor the Bbr,[A•cP�rrt:proof of azaharfuulon to s'fgrr is required Trrf s <br /> A.QTHORITATTON TO Rk7LAASE 1NSORMAT•I0: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of aay and all results, geotechnical data and/or environmental/site assessment <br /> information to Ate SAN 70AQUW COUNTY ENVA20N5VNTAL HEALTH DSPARTND;T as soon as it is available and at the dame time it is <br /> provided to the or my representative- <br /> TYPE OF SERVICE REC/ESTm: /Qevlrw &-Y'� sr�TT •/�e v//-e r .S/I-t /9 /'D C .�ll� <br /> COwIENrs. �l�t�AS 3114005 RECE ED <br /> MAR 10 2005 <br /> I(/ ,�•.nnKAn.n SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> AccLPTED BY: O L/(J f �1 A EMPLOYEE#: Q�.3 Z> TL t O/O c <br /> ASsicNED TO: �O�� S EMPLOYEE P: C.�/ _I DATE• <br /> Date Service Completed Ofekoaftcmpieted): SERVYECoDe S PIE��,O2 <br /> Fee Amcunt: ,' (C-S• OZ) Amount Paid 6S f�. Payf NFAData 3 (t7 <br /> Payrnant Type Invoice# Check f ! 3 Recehred By: <br /> EN`D 443-02-025 <br /> o neon��r�rnnno � ' <br /> 03/10/2005 THU 09:40 [T%/RR NO 97381 [ 002 <br />