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08/09/2004 15:30 4640138 LNViKUNMLNIAL HLALIH t'Aut el <br /> SAN JOAQUIN "7UNTY ENVIRONMENTAL HEALTF T F,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7ZOWNC }-S S► o�/ dao 03��S �7►� Y q 5--77- <br /> OWNER <br /> ER/OPERATOR CHECK if BILLINt3 ADDRESS 4-J <br /> 13P N 1L5` &')4S-r P e VDU&-75 L L-Cr <br /> FACamr NAME A/?C 0 6 090 <br /> SITE ADDRESS 05 s� 1ou t,5 e A I)C e� LA 71><,20p T33 <br /> Street Number Direction Name Ip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StNet Number S <br /> CITY STATE ZIP <br /> PHONE#1 <br /> T, APN# LAND USE APPUCATION# <br /> ( <br /> PHONE#T EXT, SOS DISTRICT LOCATION CODE <br /> 1 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR yc--�LK es CHECK If Eliu-ING ADDRESS 0 <br /> BUSINESS NAME , <br /> 1 C-AI 0,20A.1/'K6 -FAL PHONE ONE# EXT.7-� �n <br /> HOME or MAILING ADDRESS FAx# <br /> 5772rC-I ( 1/#- ) <br /> STATE l.4 ZIP <br /> CITY on,,Iqf-� % ,^C <br /> .,L — ::::] <br /> CJ(S i� <br /> BILLTNG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL H.EALTI-i DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN 7OAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: iL DA'i F: 3 <br /> n/� <br /> / <br /> 2-4L I <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER A7.rmoRIzEo AGENT r l��'M <br /> Tf APPL 4JVT is'not the BILLING Pproof of authorization to sign is required Title <br /> AUTgOT�IZATION TO RELEASE INFORMATION: When applicable, 1, the owner or oper <br /> ator of the property located at the <br /> above site address, hercby authorize the release of any and all results, geotechnical data and/or environn=taVsite assessment <br /> information to the SAN 70AQUIN COVNTY FNVIRONMfNTAL 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 REQUESTED: �` 0 <br /> COMMENTS: "M U LA-72-- 301 567711 SO-2. Ki 17 lj C 5C <br /> OL POPI <br /> 7 y 3 9-0 - 3 n 5PN SO11;QP <br /> N <br /> EMPLOYEE#: � 6� DATE: \O <br /> ACCEPTED BY: D.�����,� <br /> EMPLOYEE#: C6'��-� DATE. WSJ \, OS <br /> ASSIGNED T0: 'Z). t � p,( <br /> Date Service Completed (if already completed): <br /> SERVICE.CODE: �,6 \cam PIE: Qzp`6 <br /> Fee Amount: <br /> Amount Pald .� Payment Date `d ��- 0� <br /> Payment Type <br /> Invoice# Check# �0 3 J7 Received By: <br /> SR FORM(Golden Rod) <br /> EMD 48-02.025 <br />