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SAN JOAQUM C*TY IENVIRONMENTAY, HEALTH DEP. <br />SERVICE REQUEST <br />Type of Susiness or Property <br />FACILITY ID # <br />SERVIc>W rcttauts I $ <br />C:ZkS 5i"j(�� <br />�A 000713 S <br />SRoorf43©lo <br />OWNER I OPERATORgu <br />c4UK/ <br />CHWK If BILLING ADDRl:sX] <br />FACILITY NAME <br />Fee Amount:... 27 q- OD amount Pald1�- bD <br />SITE ADDRESS ;' � <br />S <br />Chack 1l` 11-7g4 <br />l O C�. <br />n <br />-T K9 <br />StreeYNumbar <br />traction <br />5tre c <br />C 21 Catl <br />Home; or MAIUNG ADDRESS (if Different from site Address) <br />Street Number <br />Street Nam! <br />CITY <br />STATE ZIP <br />PHONE#1 Exr, gPN # <br />LAND USE APPLICATION tt <br />PHONE#2 Err. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTp ACTOR I SERVICE REQUESTOR <br />REQUESTOR �CNt EGKifB`ILUNoAODRE55 <br />W i 4 <br />BUSINESS NAME PHo EXT, <br />HONE or MAIuNG ADDRESS FAX# <br />CITY C)' ®s STATE e ZIP <br />BILL'IN'G ACKNOW- LEDG.EM-ENT; I, the undeasigncd property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENviRONNE-Ni 4i. HEALTH DEPARTD�IENT hourly charges associated with this praj00 <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />AP'PLICANT'S SIGNATURE: LI % � �� �� t � �; *-Z 1: ti,- cam' _ DATE: k <br />PRovpm-ryI B(JSIN ss OWM[3 OPERATOR I MANAGE11Z U'rF m- AuTsomzEvA=--a 0Z C o fi lid MVCL. —6dVV^ <br />If APPllcftrrl is not the BrLgWG PARTY proof of authorization to sign is required T1rt e <br />AU'I'I•IQ' 17ATIQN TO BAL9ASE INFORM ON: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby autl ize the release of any and all results, geotechnical data and/or onviromental/sito assessment <br />info=ation to the SAN JOAQUIN COUNTY ENVIROKMFNTAL HEALTH DEPARTMENT as Soon a3 it is available and at the stone time it is <br />wrn,riilnri to "ma• nr mV YP.111-PCP.nfAtivP. <br />TYPE OF SERVICE REQUESTER: u� % . /,--noo x--/ !r <br />t`sOMMENYS: -._d'vKL+ - �Vt- f alu . -a4V►�UXJC� eRA <br />rj <br />L <br />LOW& ib -"Mitt WLILL <br />ACCEPT® I3Y: (✓ l„(. (' 1 i -� t EMPLOYEE#: O 32 DATE: 1 0112-106- <br />F <br />AsSlattec To: EMPLOYEE #: 3 DATE: 0 /12- /Os <br />Date S.ervice.Completed' (it already cam 2d): <br />SeRY10ECODE: ' <br />P) E: 2-5 6? <br />Fee Amount:... 27 q- OD amount Pald1�- bD <br />Payment Dam (O It 2 1O$' <br />Payment Type ... 1/ Invoice # <br />Chack 1l` 11-7g4 <br />Received Sy: <br />EHD 48.02.025 .. <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003 PAYMENT <br />RECEIVED <br />OCT 12 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />