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SeP .26 . 2005 4: 29PM WLht Environmental 832-5152 No , 1320 P . 3/6 <br /> SAN JOAQUIN COUNTY ENViRONMENTAL HF.AT.Tn I)EPAItTMENT <br /> SERVICE REQUEST <br /> of Bush s or Property FACILITY ID SERVICE REQUEST# <br /> -�1�r�1 <br /> 041 OPERATOR <br /> . CHECK If ftyb G ADDRESS <br /> f~Aciun•NAME �� A' �1t,c�'` X21 <br /> SITE ADttttk8s <br /> WJW <br /> ane G Gode <br /> H®ME ord91ALW ADDREW (Et D t from S to Address) <br /> street Numb et Name <br /> CITY STATE LP <br /> Exr' APN 0 LAND USE APPLICATION X <br /> �- .a�a <br /> PHW#2 E,. <br /> y BOS l58TRICT LpCA�dN CODE <br /> i <br /> �1 CONTRACTOR 1 SERVICE I&QUESTOR <br /> CHECK if BILLING ADDRESBtJ <br /> Em <br /> H00 or MAI Am FAX# <br /> �Tr > k,--v /�,�2 <br /> STATE zIP� <br /> G A 'DG : 1, the undersigned property or businm owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PNvikUNMRNTAL HEALTH DEPARAMENT hourly charges associated with this project <br /> or activity will be billed to Ole or my business as identified on this form. <br /> also.aertify that J have.Mpared'this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> :COUNTY Ordinance Codas,Standards,STATE and FFD13RAL laws. <br /> APPLICANT'S SIGNATURE:, DA'rE• <br /> PROPERTY/.BtnaN g FA OP=ATOR/MANAGER�] (MFF:R Aumomzen AGENT❑ <br /> If 4PPLl i r not the&LkL-NC: _&T—y proof of authorization to sign iv required Title <br /> ',&MORMATION LQM1jAff UMNALIDN; 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 and/or environtncntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMLNTAI.HEALYTi DFPARTMEN'I•as soon as it is available and at the stone time it is <br /> provided to mo-or my representative. <br /> TYPE OF SERVICE REgUt STED: <br /> COMMEWS: <br /> ACCEPTED BY: EMPLOYEE#: <br /> DATE: <br /> ASSIGNED T0: EMPLOYEE#: DATE: <br /> Data Servke Completed (N already complatod): Sr RvICE CODE: P I E' <br /> FeeAmount: Amount Paid Payment Data <br /> Payment Type Invoice# Check# Received fly: <br /> ZHD 48-02-025 (SR FORM G <br /> REVISED 1111712Im3 olden Rod) <br />