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r• <br />SAN JOAQ LINTY ENViRoNMENTAL HEALTH *ARTMENT <br />SERVICE REQUEST <br />Type df Business or Property <br />&ils <br />CHECK If BILLNG ADDRESS <br />FACILITY. 10 # <br />SERVICE REQUEST #' <br />F <br />01 OPERATORL W7122M <br />i ' V <br />, <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />r <br />MA MZ,66 4 13r hC AJ <br />SITE ADDRES <br />StreetNumberFOia- <br />n <br />__C_ <br />/I ,{, T C� tfl.Ff/ <br />S t Name <br />Ci <br />ZI Code <br />HOME or 1111AIUNG ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />P NE <br />Aga <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( 1 <br />EXT._ <br />i <br />BCS ^1ST?TCT <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTORe n <br />f <br />&ils <br />CHECK If BILLNG ADDRESS <br />P 833-07,58 <br />HOME O MAILING ADOR�SS � ^D <br />�J (_,/ <br />F7Kj A'30 -5,5c-) <br />V3 <br />CITY %yy) L <br />STATECV-,QIJ zip <br />749 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same. <br />acknowledge that all site and/or project specific HEALTH DEPART:vIE`7 hourly charges associated with this project <br />.)r activity ,.viil be biiled to me or my business as identified on this form. <br />I also certifv that 1 have prepared this application d that the work to be performed will be done in accordance .vith ail JAN J-0.AOL7.\; <br />Couvrc Ordinance Codes. Standard. STA—ic'nFEDAL Taws. <br />APPLICANT'S SIGNATtiRE: <br />DATE: v <br />PROPERTY; BUSIN-ESS OWNTERPI- OPERATOR/ . :AGER 0 OTHER AUTHORIZED AGENT ❑ <br />rt APP-rX.f v7.,s not t1?e,3aLLNG P. -1R77 proof of authorkation to sign is required Tina <br />-aU'THORM--kTION TO RELEASE IINFORNLXTION: When applicable, I, 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 andior environ mentaL,stte assessment <br />ntormation t0 the S^ ITO A01,7, COUNT"" L Y -TRC ,-,%=;TAT DF-P.ARTINfEN T as .soon as it is available and at :he sai-ne ume :i iS <br />:)revided to me or my representative. us–r-- _o IT— <br />TYPE OF SERVICE REQUESTED: Q rrfn +' yh e U 1 <br />COMMENTS: v`f} pO G�>�73 /I $ 4�Kt F� rZrJs RECEIVED <br />JUN 3 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />�10,J u F-3 7 <br />q' <br />-D 48-09-025 SERVICE REQUEST:;ORM <br />c:ISEC <br />