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01/18/2005 14:06 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> ,JAN JUAQ LOUNTY ENVIRONMENTAL 11PAI,I' _El?AR'11V1hN'1' <br /> _ <br /> SERVICEREQUEST <br /> Type of Business.or Property �� FACILITY ID tt SERVICE REQUEST# <br /> (\o bt�(�I/Li GN-C.�� <br /> a5 0l iy i i t' �4��3 .� 2��� `S <br /> OWNER I OPERATOR CHECK if Ji��Nc AoostesS� <br /> FACILRY NAME <br /> 6 w <br /> SITE ADDRESS r ` <br /> 3 3 Street Number I 01FeC1110 n V t `�r <br /> 210 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 'Street Numb J, §treot Name <br /> CITY STATE Zip <br /> PHONE#t EXT. APN fF LAm;)USE APPLICATION# ... — <br /> PHONE#2 ExT. DOS DISTRICT LOCATION CODE <br /> CONTRACTOR! SERVICE REQLTESTOR <br /> REQUESTOR ( _ CHECK if 131LLING AMR-L36 <br /> BUSIN>;S3IVAME PHONE# — <br /> EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> p o ( ) :Kq q Lk 6,2., <br /> CITY �o VvLt--' v--- e–L STATE Z:P <br /> CA- <br /> BILLIN-G ACKNOWLFI)IGA IEN?: I, the undersigned property or business owner, operator or authorized agent of sAmc, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to line Or my business as identified on this form <br /> I also certify that 1 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,STATE And FF,nEKAL laws. <br /> APPLICAN'T'S SIGNATURE: _ DATE: — <br /> PPOPERTY/BL1SnNUS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORWD AGENT fil <br /> If APPLICANT iS rto the R_&iLlNo P, ' proof of authorization to sign is required Tirl e <br /> AUTHQB17A TION x0 RELEASEINFOB IATIU»: 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 cnvironment0site assessment <br /> information m the SAN JdAQuIN COUNTY Evv1R0NMFNTAL HEALTH DEPARTMENT as 300n as it is available and at the same time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: R2 opt S <br /> COMMENTS: vS't" RST c:x-t %T ,V�D <br /> JAN 2 4 2006 <br /> 3A w AQJ-1,N C <br /> HEALTH pFP ENTAl- <br /> ACCk"s➢TED l3Y: JNJW t_JC-=S EMPLOYEE#: <br /> 83 DATE: I Z T <br /> ASSIGNED TO: -AN& wpbs EMPLOYEE#: "3 DATE:( Z6 b <br /> Date Service Completed (if already completed): <br /> SERVICE COOS: �-t98 PIE: 2308 <br /> Fee Amount ::: Amount Paid r�� Payment Date \ 2A0� <br /> 7r"i`9 � <br /> PaymQnt Type Invoice# Ch Received By: <br /> S'R-F'C3�thA"('�oldbn Ftod) <br /> EHD 48-02-025 <br /> REVISED 11117/2003 <br />