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02/26/2009 08:48 FAX _. 2002 <br /> SAN JOAQUIN COUNTY ENvIItONMENTAL HEALTH DEPARTNTENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNS OPERAT CHECK Ita OR <br /> FACIL"N <br /> SITEAwmss Lilt <br /> q3-2- –1— j`{SACOW)troalumer � <br /> HoME or MAILINs ADDREss (It Differant from S1to Addle-9s) <br /> Strad Number s� ^b <br /> CITY STATE ZIP <br /> PHONE#f ExT. APN f LAND USE APPUCAIION IF <br /> t ! fr7 <br /> PHONE iaZ Fyi. 130S DISTRICT LOCA ON CDDE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LZHECK If 9jWjqAngREss <br /> BUSINESS NAME P roup# E"T. <br /> Cv t�pJ <br /> HOME Or MAILING A DRESS FAX W <br /> Clr� StL �F L I . 15— <br /> B LINC.ACKNOW LrDGEM tNT: T, the undersigned property or I)U$InCSs owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project sWific ENVIKONWNTAL HL•ALTH DEPARTMIENT hourly charges associated with this project <br /> or activity will be hilted to me or my business as idcntifcd on this form, <br /> 1 also certify that I have prepared this application And that the work to be performod will be done in accordance with all SAN JOAQUIN <br /> COt.1NTY Ordinance Codes,Standards, STATS and FEDI: I ws. <br /> PLICANT'SSIGNATUrR�E: IDA'tF;; 9 <br /> FROPRY�It <br /> RTusTrtFsyso-, ,tt� rUtATOR MANACL�R'I7 OTI4St%AVTnORT7.F.DAGENTX e417. aaffm J!�C I <br /> YAPPT'C4NT I. nor rhe 'fmvo F fB7%progf of authorization/o sign is required Title <br /> &UU3� RIZATION TO RELEA. TE INFORMAL T_0N. When applicable, T,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotooltrtical data and/or environmental/site assessment <br /> information to the 5AN JOAQUIN COUNTY ENviRONMENTAL HT;Af,TH DEPAM'MENT as soon as it isavail I Fnf�the S81TIC time it is <br /> provided to me or my representitive. /H� Civ ' <br /> TYPE oP SERVICE MuUD: <br /> COMMbrrs: MAR 5 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �' C_t 1✓l ✓ EMPLOYRE M <br /> ASSIGN@OTO: f C.t EMPLOYEEM DATE: 3l_S ( G j <br /> Date SRrACe COmpletgd (if atraady complotad): SZKOCECODe; q P l E 7 SG <br /> Flee Amount; l Amount Paid 3 I S Payment Oute 3 S <br /> Payment Type ✓ Invotnrr# Check it Recahmd By: <br /> EI-10 48-02.025 SR PORM(Goloon Rod) <br /> REVISED 1111712003 <br />