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08/19/2002 12:45 46401 ENVIRONMENTAL ALTH PAGE 01 <br /> 1A.IV J UACZU UUl�iTX 1 J�vIk�UxvMk�V"1A.L k1 ir;AUT PAKTlV.lk1�T <br /> SERVICE REQUEST <br /> Type of Business or Property :..FACILITY ID'# SERVICE REQUEST# ' <br /> a)7Lq <br /> OWNER 10 RAT OR CHECK If BILLING ADDRESS L..1 <br /> FAoam NAME ) D 0 <br /> SifEADDRESS /3+ L <br /> 3 =ireetNumbsr Direction N=� J / ,15 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strict Number am <br /> CITY STATE ZIP <br /> PHONE#1 T APN Wo UsE APPL1CATiON# <br /> { ) <br /> PHonE#2l,ocaritiN <br /> 1' ''i y `' `,, '•... yam.. <br /> CONTRACTOR/SERVICE REQUES'I.OR <br /> REQUESTORCHECK If BILUNC ADDRE&$ <br /> $USINESS NAM E �l ` rn�'t1JgL �# g b - 702-0 <br /> . <br /> HOME or MauNG ADDiti=ssL a FAX# <br /> C�. ( s') e Vo -- 6 <br /> 11 STATE I <br /> BU.LI'NG ACKNOWLEDGEMENT: 1, the'undersigned property or busiuess owner, operator or authorized agent of same,. <br /> acknowledge that all site and/or project specific EwIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> 'activity will be biped to we 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 /> COUNTY Ordinance Codes,Standards,S7T and FEDERAL laws. <br /> APPLICANT'S SIGNAT=-. DATE; — <br /> PROP£R'ry/]Buswts. OvMEri0 OPERATOR/MANAGER ❑ H£RAUTHORfZEDAGENT) 4 A_ru L <br /> 1f.4PPIJCANT is not the BlLltt�' RTZ proof of authorization to sign is reQuired 2Yrte <br /> AUTIIOItiZAJ19N TO RELEASE INk`ORNiAT>(ON.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 environmental/site assessment <br /> • information to the SAN JOAQu N Cote'ENviRONMeNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERviCE REQUESTED: <br /> COMMEWS: R <br /> ��N 1 0 2003 <br /> . 1N��UNTV <br /> ENVIR�NMF�1�F1 NE <br /> EEf <br /> Y: .= <br /> EMP Y <br /> -APPROvEO e �' ' DATE: -`';-:.::'. <br /> Q . <br /> GMPLO <br /> A.rrS1GNFD T0:'. YEE 1(t•.. j DATE; .• .v ,.5 :r• c. <br /> pate Service•Completed (if siready eompletcd): S Cone; P f E: YX <br /> l=ee Amount:.. Amount Paid �� :i taaymecit Date . <br /> ,. <br /> RzecaivsCheck#: :.. ... d By.' ..' <br /> Payment Type. Involve <br /> EHO 4841-025 5EftV10E REQ <br /> uesT ORM <br /> REVISED 8-502 <br />