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VAI'VW^%zVll\ VVUlll } L`Alt\l,RV1V\lGl\lALalLAVanA1F.[AMAPAASI\A <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID M SERVICE REQUEST 4 <br /> �rzt o& o y� <br /> OWNER/OPERATOR VDB Y—AYt,1 PS CHEcKI191WtlGAmxMs80 <br /> FACILITY NAME KAwtPS P"PEOLT`/ <br /> SITEADmwss I.4-2-BD 1 E. t+(f7t1w(ay l20 �1Pea g53(atp <br /> S~Numhr C <br /> NONE Or MAKING ADDRESS IN DiRe,untirom Sea Address) 2-1L23 <br /> 8Oes1 Number 8bae1 Neme <br /> Crrv, (L1PDN STATE <br /> GA Z1° QW3G:m <br /> PHtatrtt IF=. APHO 2-4,7-01A-23 Land usE MPtA;AymX <br /> (scl) 5�3� 1�'>'f _3q PA - II00%-4� <br /> PHONE 02 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOuEBTOR /t'581/ R-/FCco CNECXNBILIJNO APS❑ <br /> Sumass NAME Lt\IC OftV P�K 3cog-o3"iT ENT. <br /> HmasArMALANaADDRESS *O,} VJ• OPY►G S'T'. F� ► 3(A9_03'4—� <br /> CITY (_6171 STATE cA Zr G►S`2.4c) <br /> RIlr t�,C_A,CCDMWLE.DGEMFNT, L the undersigned property or business owner, operator or outkorized 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 fort. <br /> I also certify that I have prepared this application and that the work to be perforated will be done in accordance with all SAN JoAQutN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. Z� <br /> APPLICANT'S SIGNATURE: v�'�'� / � _ DATE: <br /> PROPERTY/BUSINESS OWNERCI On;aATOR I MANAGEib OTAAT.R AOTAIo1uZED AGENT❑ <br /> If n(PP,t•Ic4w is not the BiunygPAgTY.prowfefautkorizadioe to sign Is required Tirle <br /> AUTHORIZATIONWhen 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 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 REWESTEO: 11�-GVt F-W SO%L- SO (T?% ,I t-I'Yy Sr-u-" PAYMENT <br /> DEC 2 8 2011 <br /> COUNTY- <br /> ENVIRONMENTALTHDE- RTME <br /> .. IRAtrH OEPARTYBl1' <br /> ACCEPTED BY: WT Eswwnp M. DATE: (2-12—8 <br /> As51Gwro To: —(As I GG S EMPLOYEE K: 6 DATF: 121 Z8 (/ <br /> Date Service Completed (k almady completed): SERVEECON: S� P1 E: 2-LO/ <br /> Fee Amount; ;2'SD C�o. Amount Paid '« Payment Date I Z_ T q� <br /> Payment Type Cl1 Invoice N check 0 c�( 5 Received /L4 <br /> EHO 0-02-025 SR FORM(Gcldarl Rod) <br /> REVISED 11/17/2003 <br />