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JUN-30-2006 07:57 Seruice Station Systems 408 938 8888 P.02 <br /> h SAN JOAQUIOOUNry ENVIRONMENTAL HEALTH 101RIMENT <br /> SERVICE REQUEST <br /> Type of Busyness or Property FACILITY 10# SERVICE REQUEST# <br /> Ca fwl SAT-L-0ti <br /> f�WNER/OPERATOR CHECK If BILLI DRF <br /> FAgLITY NAME '�"i L ,��' ��C..l..U�.-1 �°p•V�.�"�'.r q, `- <br /> SITE ADDRESS S ,I t o(11*Q. Pal <br /> greet Number nireetlon 10L.Lih Street Na l� <br /> HOME 4r FAILING ADDP5SS (if Different from Site Address) <br /> Street Number street Name <br /> CITY STATE Zip <br /> Fatt. ppN# LAND UsIt APPLICATION# <br /> Now#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQ1UESTOR <br /> REQUESTOR ` CHECK If PILLING ADDRESS <br /> 12 <br /> S'CY1!a-c ZiW LO'" ' 3tc vus �lrt_t:. (Ri.� e�"�.tint f�. <br /> Buswess NAME NMI <br /> E><r. <br /> HoM or MAILING ADDRESS FAX# <br /> 86 vLvtn !'tug_. <br /> CITY STATE (6A Zip <br /> 313IL1MG A.I�AIOV LEDGEIl E : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTR DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my 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 JoAQmv <br /> COUNTY Ordinance Codes,Standards,STATS and FEDERAL laws. I <br /> APPUCANT'SSIGNAL: axxL .' DATE: <br /> PROPERTY/IIUSINtss OWNERO OFERATOR/MANAGXR® OTFwR Ati-raoRimD AGENT% 9O .( <br /> IfAPPLICANT is not the BILL IRTY Proof of authorization to sign is required Title <br /> At3'I FIOI 'ATION O„RELEASE INFORMATION:When applicable,I,the owner or operator of the propeR•ty 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 JOAQuEg CouNT'Y ENVIRONMENTAL HEALTH DiSPARTMENT as soon as it is available and at the same time it is <br /> provided to me or MY representative. <br /> TYPEofSERC7E REQUESTED: <br /> GA '6�5pt"tv- <br /> ACCEPTED BY: EMPLOYEE : DATE: <br /> ASSIGNED To: EMKOYEE DATE: <br /> Date Service Completed (if already completed): SERVIGE CODE. P I E: <br /> Fee Amount: Amount.Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.026 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> TOTAL P.02 <br />