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I <br /> Aug-15-06 01 : 50P P.09 <br /> SAN JOAQU[AUNTY ENVIRONMENTAL,T-1F.ALTHIPARTME N <br /> SERVICE REQUEST SCANNE17, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5QOO 49003 <br /> OWNER/OPERATOFT /��� r CHECK if PILLING ADDRESSL�I <br /> IACiLITYNAME <br /> Fri-411A �� I�a.ndi lti <br /> SITE ADDRESS 9 <br /> 1J55G Street Number Dlrectlon S etNsme� Jl� <br /> � ZI Cetle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number trxk N <br /> CITY STATE ZiP <br /> PHONE#1 E'IT APN iY LAND USE APPLICATION it <br /> Ems' SOS DISTRICT LOCATION CODE <br /> (NONE u(� — �{�I I t7 <br /> Q CONTRACTOR / SERVICE REQUESTOR <br /> RECtUES70R ((� - <br /> f'i' � CHECK If E11�„ING ADDRE89 - <br /> BUSINESS NAME,v i'Aii J 1 V �1 f /1 Pt <br /> HOME or M4llly-ADo/�5��� cube�13A' 5/93 <br /> CITY 6UK9,i-S Fl jd STAT zip - (] <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 FNV1RONMRNTAL I ILAL rH DEPARTMENT 110urly chargcs associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to he perfomied will be done inaccordance with all SAN.ILIAo U1N <br /> COUNTY Ordinance Cudcs,Slantiards, STATF:An �E1 .RAI.laws, <br /> APPLICANT'S SIGNATURE: —Viap <br /> PROPERTYIFIGSINESSOWNER❑ OPER,%I) �n R Ct OTHER Au 1'ncuivt:IlA(;FNT❑ T� <br /> if APPLICANT iN i'tpt the Rl/./.11�'(i .IRT}'.pro f`uf aulhurization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator ul'the property located at the <br /> above site address, hereby authori7.e the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information it)the SAN JOAQ1.11N COI.INT,I'ENVIRONMENTAL HEAL'T'H Di:PARTMLN f as soon as it is available and at the same time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: `' LOC—ID) <br /> COMMENTS: u <br /> puG 2 q 2p06 <br /> AUG 9, 3 2006 <br /> SA EN0 0V R N1ME OMEN <br /> T ENVIRONMENT HEALTH <br /> Ho'a�A°�p�R PERMIT/SEPViCUES <br /> ACCEPTED BY: EMPLOYEE/t: DATE' <br /> ASSIGNED TO: JLV ' EMPLOYEE#: -59'73 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 2 Amount Paid S . qb Payment Date Q Z <br /> Payment Type Invoice# Check# Received 13y: G <br /> EHp 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />