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05/03/2007 15:14 2093651543 TANKNOLOGY PAGE 02 <br />SAN JOA,QUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERV.I,CE REQUEST <br />Type of Business or property FACILITY ID # SERViCE REQUEST # <br />OWNER 1 OPERATOR <br />FACILITY NAME <br />N o Co <br />SITE ADDRESS 7o/ <br />Street Number <br />HOME Or MAILING ADDRESS (it Different iron Site Addrass) <br />CITY <br />PHONE #t <br />( <br />PHONE Q <br />APN # <br />EXT. <br />66(o <br />CONTRACTOR / SERVICE RE <br />N <br />CHECK IiBILL ADD <br />STATE ,zip <br />LAND USE APPLICATION # <br />MOS DrsTRiCT LOCATION CODE <br />CHECK if LLING AODRE93 <br />LBUSINESSPNAME/ PHONE # E or ESS FAX# <br />STATE zip <br />acve <br />acknowledge <br />all and/or <br />dn: 1, the undersigned property or business owner, opergtor or Authorized agent: of same, <br />--A'C _ E <br />project specific ENViRONMENTAL HFALTH DEPARTMENT hourly Charge-, associated With this project <br />activity 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 JOAQUIN <br />COLNTY Ordinance Codes, Standards, STATE and FEDERAi. laws, <br />APPiACANT'S SIGNATiJR.E. rte- <br />PROPiiRTY / ftsiNF,SS OWNRR LJ OPERATOR / MANAGER Q OTHER AUTHORIT.F, o AGrNTeIQ <br />#APPLICANT & nul the &17 ING PAtt_. L ,proof of arilhorization to sign is required Title <br />LE N.F : When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JUAQUTN COUNTY ENViRONMENTAL HEALTH DEPARTMF..N7' as soon as it is available and at the same time it is <br />provided to me or my representative. <br />r <br />;e g <br />TYPE OF SERVICE REQUESTED; , <br />COMMENTS: <br />SAN,GPQ NMENTANN <br />E4\j kO <br />R VPPR-T <br />ACCERTEp BY: EMPLOYEE M <br />DArr=: <br />ASSIGNED TO: EMPLOYEE #: <br />LATE: <br />Data Service Completed (H already aomplmedy SE CE CODE: <br />Pf . <br />Fee Amount: Amount Peid 8 S Payme Date <br />Pa mens T e 5 ,3 O i <br />Y yp �-/ Invoice i� check # �•_ <br />3 S (o Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rot]) <br />