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'2/22/2008 02:44 5592665' 71 SHIELDS HARPER NO PAGE 02 <br /> .' �{ -- Dl � �'' is �►,e ��� _ <br /> SAN JOAQTJiN COLiN'I'V ENVIRONMENTAL WEALTH DL,PARTMIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR . CHECK If 4.�ILLiNG ADDRESS <br /> O?S . C.Lta�.�.a� �t n <br /> FACILITY NAME <br /> SiTEAbDRESS o ®e oiM Is o Kw�/ -P4 C.tr <br /> 21 0 street Number iractlon st mo CI Z10 Code <br /> HOME or MAILING ADDRESS (If Different from site Address) <br /> street Number stroot Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (2o°)) & 3Q ' 7-?- <br /> PKDNE#2 ExT. BOS DISTRICT LOCATION CODE <br /> t l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if B LING ADDRESS <br /> ExT. <br /> BUSINESS NAME PHONE#IDct <br /> HOME or MAILING ADDRESS FAX# <br /> Z®t?- 7Tp 4 f utr1 S ( i <br /> CITY ¢ 9 STATE ZIP 4�r3 a <br /> BILLING 'KNOWLEDGE1vIE T: I, the untlersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or protect specific ENVIRpNMFNTAL H.CALTi1 DuARTMENT hourly charges associated with this project <br /> or activity will be billed to tine 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S-r ' F and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12 - <br /> PROPr.RTY/BUSINVJS OWNER® A'roR/MANAr6R ❑ OTA$R AT)TnORIzED AGCNT <br /> I'APPLICIINT iS nett the l .LING PART),prOofofaut'horizadon to sign is required T.rlc <br /> AU1I1R17LATION TO RE]L]EAR INFORMATION: 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 COUNTY ENVIRONME•NTAi.HrAI,TH DTPARTMENT aS soon as it is available and at the game time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: F- SD ' C' <br /> It d a b ly Pe rrn L<< F " 3-74 61 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE COWPIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />