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SAN,IOAQU6. OUNTV ENVIRONMENTAL HEALTh APARTMENT <br /> SERVICE REQUEST <br /> Type of Budnns or Property FACILITY ID/ SERVICE REQUEST/ <br /> ' GPS, FA (ADD '), S2ool�oSS� <br /> OWNER OPERATOR CHMNI LLWO Aooaaaa13 <br /> FAwrrNAME ��4G/ {�A-/ ar H7�n7/J <br /> SnADWIls /./ P2rshivi9 ,�/ p S 95 07 <br /> p MASM15 Atimn Pt oxbrfd trom sib Address)- - - - - <br /> cly Zia Code <br /> "° o, rs �6 <br /> Cm H. (/r4 ro <br /> STATE <br /> PIIOIaH �• APNR LAM Yea MFL""Ma _. <br /> l�frl-► X4.2-623 ( lo - <br /> lip-o <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REouE TOR <br /> ct cc Cz 41?,e /ro <br /> swaiess RIArE a r. <br /> fFAm# <br /> IlloaEor AMIMEY <br /> ox lG 3 <br /> Ctrl STATS >y <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned Property or brdaess ahrae. peraeer or authorized agest of snae, <br /> acknowledge that all site ander project specific ENvisONMENTAL HEALTH DEPAitTMENT hourly charges associated with this Project <br /> or activity will be billed to use or say basiaen as ideidified an this farm. <br /> 1 also certify that i have prepared this application and that the work to be performed will be done is accordance with all SAN JOAQUIN <br /> COUNTY Ordinonce Codes,Standards,ST DESAL laws <br /> A"LICANT%SIGNATURE* DATE: 7—AE—10 <br /> PROPERTY/WsiNM OwNU OrcaAToa/MANAGER O 0, aAVTlKfttrisa AGtNr© <br /> 1fAPPLCANT is nor rhe$1WNG PAR1Y jrK,f Vf g"OrIZfd M 11 figN k MINklOd rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site *"ren, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONKIENTAL HEALTH IDE As as soon as it is avails le and at the sone time it is <br /> .provided to me or my representative. f7O(J ,CA+ Ac, '4421'0 iKOD C--4,v c{_{ECr— <br /> TT►s of Stat E REouE m: /S <br /> Cteasnm: ! M, RECEIV EU <br /> cc <br /> ACC"I tT: 0C-LL/,F( EMPLOYUM DAts: U to <br /> AasioM To: P"" 1 EaPLovee il: (P 2-f3 Data: -i2./ (D <br /> Date Service Completed (N dray completed): leRM COOS: j'ZZ P/E: ( <br /> Fee Amount: 2-2 0 V'O Amount Paid 4.200 , D O Payment Data -7 1yl <br /> Payment Type invoiced Cheek d 8 �� Received By:7-k/— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />