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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART mENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00020 L! taOD O 2131 <br /> 01 ER/OPERATOR <br /> 1 a ►mss- h CHEcx It B1UMG AooWss❑ <br /> SnAlsst ,^ r) <br /> 71; �'. : w[Nu`rwber. lArraeLon Street Name �ck N <br /> M <br /> Cft Mace" <br /> HOME or Mo u mi;AooREss (n owerew from sNe Address) �Q nc h o CO n e o 6)id <br /> Street Number StrMt me <br /> CITY <br /> STATE Zip <br /> PHONE#t Ext APN# LANG USE APPLICATION# <br /> (�45> Q <br /> PHONE <br /> 92 Exi. EM DST LOCATION CooE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOu �^ �_I <br /> E OE L r INCL L jQt r j 7 <br /> CHECK if Bu1At3 Aop ❑ <br /> B N <br /> A Q�r� a m ,r -� �h P S " 1 S i <br /> HoIrE ora N Dgii, FAx# <br /> e r a <br /> CITY GSI ) 5 85• ��I q 9 <br /> i [� <br /> —f 'Fora ILr STATE CA zip <br /> LI-ING ACKNOW :HENT: 1. the undersigned property or business owner, <br /> rod ect� operator or aut<Mrized meat of sloe, <br /> acknowledge that all site and/or <br /> p ► specific ENVIRONMF.NTAI HFAI.TIi DFPARTMFNT houTl_v charges associated with this project <br /> or activity will he hilled to me or my business as identified on this Gornm. <br /> 1 also certify that l have prepared this application and that the work to he performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes.Standar&,STATF and FFDFRAL laws. <br /> APPLICANT'S SIGNATURE- -� � <br /> — AS -- -- —.— DATE: <br /> 1'Ro/FRTy/13Us1NE1ti UWIVEFIt <br /> R U► A /MANAGER ❑ U77iFR AlI <br /> TIMMMM AGENT❑ <br /> I/APPL/('ANT is not the B/Lgh p tM pMefof,,Whori�"oR m sign�"reqa*edTitle <br /> A>Il3 MMAT70N TO RILIJAM ImFogu&M;: When applicable, 1, the owner or operator of the <br /> 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 JOAUUIN COUNTY ENVIRONMFNTAI.HL•AI I I I DFPARTMFNT 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 /> C�,s: <br /> i,rN a Q W i � <br /> j_0 0.) <br /> MAY 2 2005 <br /> I l <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> ACTED By EPART E <br /> EMPIAYEE#: DME: <br /> A comm TO: a <br /> --- S',,�-�•_� EMPI.oYEE#: 'Z� DATE: <br /> Dais Sotoe Contplebsd (if ahssdy cornpft SEWAMCOOE: ✓�� PIE: �3 <br /> Fee Amount. 7 Amount Paid CC 0 Paymi nt Dae S G <br /> Payment Type ✓ Invoice# Check# <br /> Reexivad By: <br /> EHD 48.02-025 <br /> REVISED 11/172003 SR FORM(Golden Rod) <br />