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SERVICE -REQUEST <br />IiI.L TN(3 ,RC 0nLA,)DGt +Jti : 1, tbo undersirnvd properly or business owner, operator or aulhorixea aocnt of same, <br />acbsowledge tbar all site Rnd/orproject specific ajSociated with this project or <br />activity will be billed to me or my business as identified on this forrrL <br />I also certify that I have prepared tilts apTslication abd thot the work to be performed will be done in socordar:cc with lilt SAN JOAOUIN <br />COUNTY Ordinance Codes, Slandmds, STATI1, and FEDFRAL laws. <br />APPLIcA rs sicNA'('>v",.. � ___---- IDATk;:-- <br />PR�rlCnrr / >3uslrvcas Owna R ❑ OrK 'rota; '�tANAGEn OrKMAVTFi'Oir'l7, 0 AC;rN'T ❑ _ <br />4nPrdCauTiv not tks IlY ,Ileto sign is re aired <br />4Ai`TiT.01(tI_ ZATInN TO Dr.TX., ti PIAN: WRa,n applicable, Y, the owner or op®raitor of tho property k-WoO at the <br />above site address, Wahy authorize the release of atly and ;dl results, geoteclv&al data and/or elavironYnental/site aswegsMtra <br />irlformadon to t6 SAI'' T() Q,OLN COLT'TY r5WM0NML'NTAL 1IaALTH . EPAR7MTNT aS SOOu n9 it is av01.131110 and at Lhe Sc^rnc t�m 1t IS <br />provided to me or my represcntarive <br />Type of SERVICE RFOUESTEO: <br />1 - , i6 <br />COMNEMS: yI �, � 11 , E aIT <br />+ e, �l. ' + nj'"Ih` (��'� lA <br />�1 <br />PR 2 6 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />DEPARTMENT <br />��EALTH <br />ACCEPT50 BY: / EMPLOYEE 6: —2 ' � <br />0PTE: <br />ASSIGNED TO: EMPLOYEE$: �`�DATA: <br />— -- <br />— J._,..�.....,.,.^ <br />Date Service ComDloted ()i already complexed), SERVICE CODE: <br />P l E: <br />Fee Amount; c1� AmoUnt Paid r Payment Date <br />_ <br />Payment Type c/ Invoice w� Check 7t s Z S Received By: <br />EHD 48-C2425 - <br />REViSED 11/17.1+-f 1 0' +0 M <br />CO/Ce 39dd s9niQ SJ-Mi139 <br />alk I�ORM,(Go10et►'Rotl) <br />9C0989660Z 6Z:ST 90ez/5Z/be <br />