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F29., 2® O'� 0� C34 PM SHIELDS-HARPER & CO. MOD 236 0185 P. 01 <br /> C'L, 4l Ie. <br /> DEC 2 9 Lr,. ; SAN 3oAQUTN CouNTY ENMONMMKTAL HEALTH DEPARTMENT <br /> -�, SERVICE REQUEST <br /> TypelBusl or P rt/y FACILITY 10 S SERVICE REQUEST i <br /> / 'AF <br /> J !2 LF4 o0o IW `i <br /> OWNER l 6PIERATOR , CNFGK tr�It.t.luo Anne <br /> Req <br /> FACILITY NAME <br /> SITE ADoREss <br /> 4 <br /> HOME or MAIuNO ADDREss (if werent f vrn She Add <br /> N <br /> CITY STATE ZIP <br /> PHONE s1 E". APN 0 LAM use APPUCATION <br /> (Z®ei) 839 - 7Z <br /> PHONE ! axr. E03 DWTR CT LOCATNaN CLO! <br /> { <br /> CONTRACTOR/SERVICE REQUESTOR <br /> R,EQUESTOR 6P 0- � CHECK If nUJNa A 2MM <br /> C a <br /> INEss NAME <br /> PHONE'20'4.2 m ur' Si (;tell <br /> , <br /> 5 2_q -* rZ_P— <br /> HOME or MAIt.INa ADDRESS Fax S <br /> t l <br /> CITY l4y)® S STATE ZIP 9"r 3 S® <br /> BILLING ACKNOWLEDG : I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DP..PARTMBNT 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> 1 <br /> APPLICANT'S SIGNATURE: s h DAra: <br /> PROPERW/DUsrNUM OWNERIV oPERAToR/Mmm= d OT=R AUTHOMZM ACENT❑ <br /> If APPLicA t not the BILLtNG PAR Pmef of authorization to sign h required Tule <br /> AIMORIEATION TO RELEASE INFO UW-. When applicable,I,the owner or operator of the property 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 JOAQUIN CotiNTY ENVIRONMENTAL HLALTid DEPARTMKNT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVCE REQUESTED: <br /> COMMENTS: VIZ OF Faoxg C... <br /> kr 370 <br /> AccepTao BY: EMPLOYEE S: DATE: <br /> Asa GNFO TO: EMPLOYEE#: DATE: <br /> Date Service Comp (M already completed): SERVICE CC01: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Gheck a Rec Dived By: <br /> EHD 48-02-026 SR FORM(Golden Rod) <br /> REVISED 11/17/2001 <br />