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05/19/2011 i5:05 209G64Q738 ENVIRONMENTAL HEALTH PAGE 62/02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFiPaRTrvlarn T <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUE5T# <br /> OWNER OPERATOR + `kzo&'2 <br /> L <br /> Faclu y NCHECK If B3 NG pp 13 <br /> gMf;ROW-4A- ' V-kc e� <br /> SITE AMRF <br /> 7 '9t ew}um er (a LACI IZ45 <br /> NAMEer AILING ADDRE$3 4fDifferentf`rarnSitaAddren kkwe c <br /> t+1TV W!\ St/0lk Nvinboe <br /> $T ZIP <br /> PHONE1 fiFT' APN P <br /> GIM ni—&0 Q� LAND USE APPUCA'110N# <br /> PHOW4 V FKT <br /> 1 ) BOS D1srrllCT LacAfloN CeoF <br /> CONTRACTOR f SERVICE REQUESTOR <br /> Requ@STpR <br /> L E � -5 DrCHECK IfA!L y [� <br /> EIVSINt gs NAME L C gey- i c�5 <br /> PHONE# �, <br /> HUME or MAILING AADRESS <br /> 3 frZ ! Fie- - �►� < FAx 0 <br /> CITY CJ l '� Ll �( 3- <br /> STATE ZIP <br /> GE1►�IIEI♦ : I, the undersigned roe <br /> acknowledge that all site and/or nroiecf spe4ifiC �NVr O NI NTAL H ALTH 0L••PAR1'rut�dTrhou y hargesoperator or a3 coo aid wrized gitnhiof snore, <br /> or activity will be billed to me or my business as identified on this form. project <br /> I also certify that I have prepared this appl' ion and tho.l the work to be performed%vill he dorlc in aocordaltCe with all Sax JoAc�UrN <br /> COUNTY Ordinance Codas,Skandarrls, A F nd F T)�RY\L <br /> APPLICANT'S SIGNATtIIRE: <br /> PROPERTY/$USINP.y3 OWNER 4..1 DATE: �" r <br /> CjPEkATQR/11ANACER [� OTnFRAtITN0Rt7,ED Act,-,T 2 <br /> T 8 <br /> .4 PP K-ANT is rrvr thv 13tr�jh�ngR�1_proofof authnrizalinn to sign is required <br /> ORI �fT IY Tp R (EASE INI <br /> above site Address hQMLT-20-N:When applicable, I,the Owner or operator of the property located at the <br /> orcby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> inf ll-Ma11orr to the SAN JOAQU1N COUNTY ENVTRONwNTAI.HEAt.TH UP.PARTtv1G`T Os Sp <br /> provided to me or My representative, on it IS dv.i7gbie and at the carne time it is <br /> TYPE Or SERVICE REQUESTED: GAS T <br /> CaranxNTs: <br /> F�T— YMENT <br /> REC <br /> spy 19 2011 <br /> SAN JOAQUIN COUNT? <br /> EWIRCNMENTAL <br /> vcW <br /> ACLtrEPYEb Et.1PLOV�r,y/; �+�7 <br /> Q DATE: KE: <br /> AuSIGNEO 7fl: tb-u EMPLoYHE#t �] DATE:Date Service CGrApleted (if already complated): srmacr covr.: ! <br /> Fee Amount: 3 G -- Amount Paid b Payment Date <br /> Payment Type Invoice# Check# RPcelved By: COY <br /> EIRD 4&02.025 SR FORM(Golden Rod) <br /> REVISED 11(1712603 <br />