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08/29/2005 15:43 20946435G5 VALUED ENGINEERING PAGE 03 <br /> SAN JOAQITI.N COIINTY EwrRONMENTAL HEAT,TFIAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Preporty FACILITY M# SERIACE REQUEST# <br /> 4,c,0 �r�e. �is sirup ci �i bDU o��FrT <br /> OWNER/QUEATO <br /> CHECK IfBILLING ADDRP:SS <br /> FAGIL ME <br /> SITE ADDRESS . f <br /> SO u bar (� Strmat Nn c I 0 <br /> HOME or MAILING ADDRESS (if DiPfcl+cnt from Site Address) <br /> 64rogt Number 3tsest Ma <br /> CITY STATI; zip <br /> PHONE#1 Esc APN# LAND Use APPLICATION* <br /> (20q) <br /> PHO) LOCATION <br /> #2 l En. 808 DISTRICT com <br /> llr�xJ (% CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE5 f= ne C I CHECKBILLING ADDRESS <br /> BUSINESS 10 <br /> NtE f � � PHDNEIR ate' � <br /> Z I ej C�E'X I (l 209 ZD <br /> Homuor MAILING ADDRESS FAX <br /> CITY STATE ZIP <br /> MLL0G-AC,KNQW ,EDGTLIN LLT: i, the undersigned property or business owner, operator or alltborfzed agent of Name, <br /> aeknowkdgc that All site and/or project speeifl.e FNVIRONMRNTAL HEAr.TFZ DEPARTMENT"hourly ebarges aSsnciated with this Projcct <br /> or activity will be billed to me or my hmAness as identified on this form. <br /> I also certify that I have prepared this application and that the work to be perlbrmed will he dome in accordance with all SAN JOAQUIN <br /> COuwnf Ordinance Codes,SRarndards,STA w1q- <br /> 4 <br /> APPLICANT'S SIGNATURE:' AAT(?;: F21-6 <br /> rRor>4 R[Id' <br /> RTY/ U9INESSOW OPERATOR GER 0 OTTI RAn'rnoRr7m)AGENT❑ <br /> T'Annrrc.Avr i.s not rheByrir G PARTY.prnorof authorizadon to.*#s it regstired Title <br /> AUTPHORIZAnON TO RELEM9 INItORMATION:When applicable,I,the owner or, operator of the property located at tho <br /> above site address, hereby authorize the release of any And all result:a, gcol:echnical darn and/or environmental/site asscssmcnt <br /> information to the SAN JoAQurN CouNTy ENviPoNMVN'TAL HEALTFI ALPARTKENT as soon as it is available and at the same titn4C it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACcEPTEE7 By; EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#': `s t� DATE: <br /> Data Service Completed (it already completed): SERVICE CODE: ' Ct 8 PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Ss' Received Ely: <br /> E1-1I7 48-DZ-025 SR rORM(Golden Rnd) <br /> REVISED 11/1712003 <br />