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1 FROM :BSSR, INC FAX NO. :6615882786 ug. 10 2006 08:59AM PP2 <br /> 79 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DSPARTMEN1~ <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST III <br /> OWNER I OPERATOR <br /> FACILITYNAME q (� <br /> SFMAMRESS J 5 0 f •J 00 v4k LTob ,. � <br /> c <br /> HM or MMLM ADDRESS (if DHbrant from Sibs Address) <br /> m <br /> orty STATE ,ZIP <br /> PH91 <br /> ( g) 15 F-l L4 (Li <br /> 1 APN$ 4.0040 Use APPUCATION 8 <br /> PROW#2 1 ' BOS 08TPJcT Lo"1110N Cone <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuESTOR 2 y-e.-� f_U <br /> �'� CH9cXif13tNGAD <br /> BuswEsa NAME J--�4 PH Exr. <br /> Noble or MAtuNt+ADDRESS I ^f . '(� Fax# <br /> CITY STATO Gh ZIP t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 1•IEAimi DuARTMENT hourly charges associated With this projoct <br /> or activity will be billed to nae 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 JoAquN <br /> COUNTY Ordinance Coder,Standards,STATE and FERMIAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7— � l�0 b <br /> FRopnw/B amass owNNr I3 OpF.I ATO-A/MANAGGIR.© OTH&lt Air MORMI)AO , 13-s5,z' <br /> f,4PPLICANT 1.8 not the n 7 proof of aamorlwaon to sign is requireir Tilt <br /> AUTHORIZATION TO RELEASE.INFONATIOA(:When applicable,1,the owner or operator of the property located at the <br /> above sfte address, hereby authorize the release of any and all results, .geowohnical data and/or onvironmantal/site assessment <br /> information to th®SAN JOAQUIN COUNTY ENVIRdNmENTAL KFAi.TH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my rt presentative. <br /> TYPE of SEiimE REQUESTED: / PAY i7l E N! <br /> commem: <br /> AUG 10 2006 <br /> e?16 SAN JOAQUIN COUNTY <br /> ENVINONMENTAL <br /> 8EATH DEPARTMENT <br /> Acct=pTao By, l;MPL'OYEE 4: DATE: <br /> AssioNEDTO: I NIPLOY0E+4: DAM <br /> Date Service Canpleted (N ansaady completed): sPR=Cour: P 1 E fj <br /> Fee Amount ' Amount Paid Payment <br /> Payment Type •�1 Invol4:e t1 ��D Rode' By: <br /> ENO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117P2003 <br />