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JHN-J-CVk3C: 11:cJH r RUI'I; I U;171b13 rc:lid rJ Y:1 <br /> Maw 07 07 11:25a JP Pet�lleum Service 916372487 3 P.3 <br /> SAN JOAQUIN COUNT/ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type ol liusteM or Property FACUY ID SERVICE REQUEST# <br /> �n'1 <br /> 0VWWR I OPERAVOR CHEM tt BILLING AOORESa13 <br /> FACILITY OW ' u <br /> �t•� (� s�,.�Nie.. (1'1Gr � ��� S{->✓�C.K <br /> HomE or MALM ADDIt SS Ilt OM W*M boon 21te Adorossl <br /> + <br /> NumOvr t <br /> CITY STAVE Zip <br /> r T- AVN i LAND Uaa AMICATWN• <br /> tp�i fly 3'S2�r� 14 '� <br /> P"*W#2 �+ BOS USTRICr LOCATION COOS <br /> t t <br /> CONTRACTOR I SERME REQUESTOR <br /> REQtIESToR '� t , `ce— ClrtGrdB++tlwcAoowEal <br /> BUSINM NAME '"C11t1 �^lr�l LLmct C�L .`xW 3�.�-s�a j <br /> Home orINAtuNcAadiES8 �� IL1�C• -- (//(,l ��--r7�(Y� <br /> 7C-�,�,! STAYS ZIP <br /> BILLING ACKNOWIXDGEMENT: 1, the undersigned property or business owner,operator or aatbarlized agent of same. <br /> acknowledge that all site llndior project specific EIVblRDNmLNTAL HcatTH DF.PARTMEINT hourly charges associated with this project <br /> or activity will be billed to me of my business identified on this form <br /> 1 also certify that 1 have prepared this eppl' and that t work w be perfOrmN d bn dune in accordance with all SAN Jonptmv <br /> CDum-T Ordinw+ce('.ales,Sta►rdardt. ATE P=o .faw . ��� rte^ <br /> -� APPLICANT'S 3IGtiATUR _ DATf <br /> Pleorrrerr l Bust+s550wNErt❑ OKM"W I N1A�aGae (YntFm Amm>wzcu AGENT(31j,4PPc1CA,7 is nv1 rhe ZLIW- :l',Ut ry pravjajaa!lrarizadun to slgrt Is requited rule <br /> AUT110RIZATI TN TO REI RASE INFORMAT'UON;when applicab(t.1.the owner or operator of the property located at the <br /> above site address. hereby authorize the release of any and all results: gtotechnicat data and/or tavironmental/sile assess=nt <br /> information to the SAN JOAQUIN COUNTY ENVIaONMENTAT.REALT11 DEPARTMENT AS on as it is available and t<t�+r is <br /> so <br /> provided to me or my representative- <br /> TYPE OF SERM REOWSTEo: <br /> Cae&M.- MAY <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> Acce"W By: Emp oTEE M 3 DAM. <br /> ASSIGNEo To; tfaltPLOYlw N: DATE: <br /> Dasa Sewke Completed (it abaady"mO004111: St7CYICE(.ODE PIE. <br /> Fee Aewunt Ar5 U Payment DaOe �j ( g <br /> Payment Type?E4H�:� <br /> eck ax Dq I Racelved By: <br /> E►1D a8.OZ-025 SR FOR7� ;oWp Rom <br /> REVISED 111171ZO09 `, 5-71 <br /> G7 <br /> 4 <br /> R -` C3� <br /> ('�� <br /> w r..n— _ <br /> - <br /> JAN-3-2002 THU 11:09AM ID: 1�GE <br /> > <br /> %0 <br />