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SEP-02-2008 15:06 MID—VALLEY ENGINEERING 2095260803 P.O2/04 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M apse 159066542 <br /> OWNER/OPERATOR CNECN It BILUNG ADDRFHS❑ <br /> AQW14 ✓hWOER _4nV-qV?:rA0g&,0y, /S/AG77ER <br /> FACILITY NAME <br /> SREADDRESS /A,lu?2 E 4,*."4 r 7%dw q,=, <br /> 3b 1 Nu~ O efion <br /> HOME or MAN-ING ADDRESS (H Different from Slee Address) <br /> 9Mee1 Num4ersyen xame <br /> Cin, STATE LP <br /> PHONE in En. APNIt LAND USE APPLICATION <br /> (god)) 838'343 1 r 07-c4a^61* CMS) <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( Z 403- a 175 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CHEM If BILLING ADDRESS11 <br /> Sf�YYCE 7 KpM C.til <br /> BUSINESS NAME <br /> ibf✓E �l✓�4 SaYuno�vS <br /> HOME or MmUNG ADDRESS FAX# <br /> CIT/ pA6�Tp <br /> STATE Gh Zip <br /> BILLING ACKNOWLEQGEMIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <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 /> I 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,STATE',and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: !"a O0 <br /> PROPERTY/BUSINESS OWNERQ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT <br /> !f APPTJCAA'T is not the AILLZNO PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 1j FORMATION: 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 envirotmmental/site assessment <br /> information to the SAN JOAQUIN COUNTY EN1{IRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED; PAYM <br /> COMMMS: <br /> SEP 19 20)8 <br /> ,oil SAN JOAQUIN COU TY <br /> ENVIRONMENT <br /> HEALTH DEPARTME 4T <br /> ACCEPTED BY: EMPLOYEE#: DATE' <br /> ASSIGNED TO; EMPLDYEE#: DATE' <br /> Date Service Completed (H almady compiated): SERVICECODE: �� PIE: <br /> Fee Amount: (Amount Paid Payment Date <br /> Payment Type Invoice M Check# Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />