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SAN,TOAQ'UIN COUNTY ENMONMENTAL HEALTH DEPARTMENT' <br /> SERVICE REQUEST <br /> Type d Business or Property FACILITY ID 0 SERVICE REQUEST A <br /> t7b11�It3R ' <br /> GMltCKiF BEw <br /> �FOVAULFTYNZF <br /> HOME or 11,uma Amon M DRrorent from Sita Addraas) cry <br /> cads <br /> t <br /> envSTATE ZIP <br /> PF1oI #t EXT. APN# LAND Uss APPLICA7 m 0 <br /> � 1 <br /> PHONE 12 IBM BOB IyiiFwTLOt:AWON CODE <br /> { ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> FtEQUi�1'4 <br /> CHECK If BM llNtaA parr❑ <br /> gni AMIE PHQNS# ear <br /> < . o "DRESS FAX# <br /> OW Stq r r,.r <br /> BILLING AtKQE)yG1Elt,[ �; L the tmdersi ned ro 6 <br /> acknowledge that all Site ar>d/or project SpOW&ENVIRONMi rr HEALTH DhPAI TMCNT hourly cha or authorised spent s Homet <br /> y charges as$aciated with this project <br /> or activity will be b111ed to In*OR MY I)aslne s as identified an this form. <br /> I also certit,� that I have prepared this application and that the wprk to be perFormcd will be done in 9=dance with a115AN JOAQUIN <br /> ou. m Ordinance Codes,,Slandatds,STATE and Ism m laws. <br /> A PLICANTIS SIGNATURE: ^ DATE: <br /> m,.g <br /> PRorcnrlrIBusowmp.RE3 OrEPATOR/Rl C m. �THFRAU1RORr�LbACsa+1Tl <br /> #f APPLICANT is not the!Jr R ,pro8f ojaklhoriativ►t to sign is reqUlred rr lle <br /> AUTHt7 TO RELEASE I •When appttcahle,A,the owner or operator of the property located at the <br /> above Site address, hereby &Ilthorize the release of any and III results, geotechnical date and/or environmental/site assessment <br /> infonim Ion to the SAN JOAQUIN 00urfrY ENVIRONMENTAL HF.AI.,Tii OwARTmaN1'as soon as it is available and at the sante time it is <br /> provided to me or►try representative. <br /> Tvpt of SERVIca:RMUP.at9Ml: <br /> �: Car�rts; <br /> R C <br /> MAR 4 2009 <br /> SAN JOAQUIN COUNTY- <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Aactprets Far: EWIpI gYRJq fi: PATE <br /> Amo=m, EEtPLOYEE DATE: <br /> Data 86M*CcmpleW Of already ae oeftd)e s�+nce Coca: �1 <br /> Fee Amount.' 'S c Amount Paid 3 S Psyme tR <br /> PttynienkType ✓ Inv131ti0# Chocks t,,S-(0 3 q IRat'elvod Syr: <br /> EHD 4&02-025 <br /> FiEV1SHC I SIR FORM(Golder+Rop) <br /> SE13111 M 71003 <br /> f' <br /> f <br />