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OCT-07-2005 02 :23 PM TOM 7UCKERNPN 1 209 7454792 P. 02 <br /> M i, r, R05 11 : 08AM F )9-946-0296 N0. 4314 P. 2 <br /> SAN JOAQcur COUNTY E]\MONMENTAL HEALTH DEPARTmrim <br /> SERVICE REQUEST <br /> Type of Sualness or Property ==FACILITYb# <br /> Agriculture 1 l6TRT0 <br /> ''R f�Q�aroR Brovelll Woods LLC <br /> C>+�mc if <br /> FAgU17NAME Brovelll Woods <br /> &rmAD°m 250-0 I Wild Hare Lane <br /> A mpo 95220 <br /> HOME Ot•tiIAIL{NO ADOitE88 (I!Df(t'vrent imm 81ta Addnm) <br /> 1610 N. El Dorado 3t., Sts.#7 <br /> F(209)464-7658 <br /> Stockton7 STATE CA 95204 <br /> Lv <br /> w LAND vee APFUCAiro �� <br /> � 003-100-25 .�� <br /> Unassi n®d <br /> P�tf2 e,.,. L <br /> ocal WNW <br /> CONTRACTOR!SERVICE RE UESTOR <br /> REQueaToR Abby Racco <br /> chEcx if <br /> SUSINiee NAwr PKONd# mr►_ <br /> Neil Ass 20 7_ <br /> 3701 <br /> 14CURoarMacnaAwR as Pax# r. <br /> cm Loll s7ATR <br /> CA ZIP 95240 <br /> I, the undc"lgped property or business owner, operator or authorized agent of came, ` —� <br /> acknowledge that all"te and/or project Speoiflc ENVIRONMENTAL HEALTH DEPAR'IMFNr hourly charges aasocinted with thls project <br /> or activity will be billed to we or my buafnaee as Idead$ed on this form. <br /> I also certify chat I have prepared this appliostion aad that the work to be performed will be drone In accordance w1th] I SAN JOAQVW <br /> COUNTY Ordlnmrce Codes,SYandvrc�,PTATB WS, <br /> CAN ' iNTRA [ ll[°rl f �1 �-.LC_. �✓) <br /> DATEi <br /> PRO"AW/BV=Nzss Owr4XR a /. n&wnCC OTHER v'r'aORMM AMLNT❑ <br /> YAPPL1GNIis.not the fiU4,a�pro ofauthoNt don to sign Is regulred T1lto <br /> AU?BURIZATIQN TO RE L4,, ±Lrp tNeUoN:when applicable, I,the owner or operator of tho properq•located at the <br /> nbovo site address, hereby authorize the rolec>so of&ay and All rceults, geotechnical data and/or envlrontnenmysite assm�ement <br /> information to the SAN 7OAQUIN COUNTY ENVIRONMBArtALHEan DBPAATmENT as goon As it id evailnble t o Same time It is <br /> provided to me or my repr sentffdva. P� D <br /> TYPE of SERVICE REpUMeD: <br /> CowlttJtre: D O <br /> /;/16��D/n(,,1 SP SOP ON EN1 EN <br /> N��t�Oc� SSM T <br /> 17�te9vice Completed <br /> Paid Amaurrt: AmrauAt Patd U7) Nyment Cts <br /> �60t ty w ✓ l rtv r Q 7 t7 S <br /> �3 o <br /> END 4ED"-d 6.6t, <br /> REVISED 1 SERVICE REQUEST FORM <br />