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12/05/1999 11:07 4760135 WONG ENGRS PAGE 02 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY!D# SER E REQUI'� <br /> OWNER I OPERATOR <br /> Md-V l LM if$IDLING AapRE55 <br /> Patau NAmE <br /> SI7TEh AO#RE5S <br /> kt4Cq It4•I w "�.< �.i I <br /> f �~ ` <br /> HOME or INARING ADDRESS (It Different from Site'Address) <br /> L-N <br /> CITY STATE Zi <br /> Ll <br /> Pr{ON€Al Exr. APN J! LANG USE APPUCATIGN# <br /> N{SG0�� ms%- � <br /> PHONE 42 80$DISTRICT LOCATION CODE <br /> f ) <br /> CONTRACTOR ! SERVICE REQUESTOR <br /> REQUESTOR <br /> 440 tr_ CMCK it @ILLING An#WsL.1 <br /> fttIJINESSIk M PWNE S E:r. <br /> ' �rE 1 <br /> HOME Of MAILING ADDRrLss FAX <br /> 45-72 <br /> CITYSTATE` k- ZIP <br /> �� rr �r, <br /> I 'A-CF 0iQ!n�DGE�1EN' I, the undersigned property or business owner,ioperator, or authorized lagent of game, <br /> acknowledge that all site an&cr project speciric Ft,lETIIC HEALT14 SERVICES EivVtr;pN [ENTAL HEALTH Dr/ZION hourly charges <br /> associated with thio project or activity will be balled to me or my business as identified an,this form. <br /> t also certify that I have prepared this application and that the work to be perforated will be dons in arxnrdau 10 with.all SAN JOAQLnN <br /> COUNTY Ordinance Codear,Standards,STATF and FEDERAL laws. <br /> APPLICANT-S S[GMATiTEtE: „� s�� � DATE <br /> PaOPERTY If BUSINESS OWNWA OPERATOR�'IVUKAam DrHEit AuTHoRwzra AGuwr <br /> 1f APP1.ri7,INT is not'the&LLiNG P.larl pr4mf of ourkorfxatiou w sign is mquired x fres <br /> A1TTkICItIZAnUN TO RELEASES 31IAUM: When applicable, 1,the owner or oger$t r of the property locatad at the <br /> above site address, 4ereby authorize the release of any and all results, geotechnical data and/or environmental/site assem anent <br /> iitfarapat 011 to the SAN JOAQUrN COUNTY PUBLIC,HEALTH SERVICES ENVIRONMENTAL HEALTH DmSlO9+1 as sq(M 45 it is available and <br /> at the sane time it is provided to nye or ny representative, <br /> Tyn OF SERVICE fiC UESTBO: <br /> JUL 9 <br /> $RW C JUFJTY <br /> PUfli-IC RE447H St MnCEr S <br /> 4f' "ONMg TAL HEALTH DMSION <br /> IIISPEC70R'S SIGxATURF; COi RACTOR'S S1('iNATURE. <br /> APPROVED(3y. �"� �� EMPLOYEE Ile: 5 r 3 BATE: <br /> ASSIGNED To: """t-ayEE#: _ 171 DATE- 7 <br /> Date Service Completed (if already'Completed): SERVICE CanE..S'c- � �� P t E: y2<71 <br /> Fee ArnotAnt: Amount Paid Payment Orate <br /> Payme6t;ype Receipt 0 Chock# Received By-, <br /> s KREQt rv�ioc VIM" <br />