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08,'09/2004 15:30 464013M LNVIKUNMLNIAL HLALIH IlAut 61 <br /> SAN.JOAQUIN G&UNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business Or PropertyFACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLIN®ADDRESS4...1 <br /> FACU Y NAME A(-Wc <br /> SITE ADDRESS 77!�N�mbg <br /> tq: C L (7L�l ��i S �2 E 1 5 ZC �7�n(StDirection rr Name I ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> St ek Number 5 <br /> CITY STATE Zip <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR jDyEK_g_ES C/iECKIfB>LLINGADDRESS❑ <br /> PHONE# <br /> BUSINESS NAME A I ) "V�2D/vME747-AL- 5`/5 i C"i S �/� 25b 7 -6 q0 Z <br /> HOME or MAILING ADDRESSFAX# <br /> (8-t,3 4. ( J/4) &r5 -UDD(c <br /> CITY 02,E V-- STATE CA- Zip 9 _�2�&S7 <br /> BILLTNG ACKN WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVTR.ONMENTAL H.EALTi-i DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or illy 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 JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FnDERAL laws. <br /> APPLICANT'S SIGNATURE: P, 11� DATE: 10 --7 -04 <br /> PROPERTY/BUSINESS OWNEROPE R/MANAGER 13 OTHER AUT7mRIZEAAGENT Y4cl0 � <br /> Title <br /> If APPLICANT is'not the BILLING PAS proof of authorization to sig,is required <br /> AiJTHORIZATIO TO LEASE EORMATTON: When applicable, I, the owner or operator of the property located at the <br /> cal data and/or euvironmeptaUsite assessment <br /> above site address, hereby authorize the release of any and all results, geotechni <br /> information to the SAN JOAQUIN COUNTY F.NVTRONMENTAL HEALTH DEPARTMFNT as soon as it is available and at the same time it is <br /> provided to me or my representative. (f <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RC-PLACE—b SSI SyP+I�'tic F�L� S5"M P , I/Id ��Dc Y p <br /> 7C1 4 3,�V --20Y OCT 8 200 <br /> DA <br /> ACCEPTED BY: EMPLOYEE#: EN�1l <br /> � EMPLOYEE M DATO <br /> ASSIGNED TO: V1 oP 1 E: V C) <br /> Date Service Completed (if already completed): <br /> 5eitvlcE CODE: Gi � (, <br /> Amount Paid Payment Date /D $Zd I f <br /> Fee Amount: �-7 ' � 0 <br /> Payment Type Invoice# <br /> Check Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02025 (�j )�4 <br /> ��...w A/A 717/�N�J �5✓ <br /> I <br />