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06/30/2010 16:07 9169147n38 GEREMIA POOLS PAGE 08/12 <br /> r' SAN JOAQUIN COUNTY ENVIRONMENTAL DEAL i :[DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Suslness or Prop orty FACILITY Il)# SERVICC REQUEST# <br /> OWNER I OPERATOR r CHECK if BILLI g ADOgESS❑ <br /> FACILITY NAME Lr <br /> $rrE ADDRESS /_ � /) . <br /> 64raet Num>rrr bireetla auzy5 <br /> Ity <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Nurhb¢r Strac+ � <br /> city STAT£ zip <br /> PHOEfE#f <br /> Exr, APN# l�uD Use AppLlGerrQN N <br /> M(6) tl.�? [P <br /> PHONE #2 DOS blSTrt�cr LbannoN CODE: <br /> CONTRACTOR/ SERVICE REQUEST'OR <br /> R7 Q'UESTOR { , CHECK if BELLINAADDRESSL� <br /> BUS1N£SSNAME{l PHaNE9 EXT. <br /> 0 1 Q►/- -7 <br /> HOIW" FAR# <br /> Omr STA /� zIP <br /> PJJ=G I IVp GE : I, the Undersigned property or business owner, operator or authorired agent of same, <br /> acluiowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified an 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 Code',Standards,STATE and FEDERAL laws. <br /> AIPPLICAIVT'S SIGNATURE: t--I DATE: � LV7 -�-L- ---L <br /> — <br /> �tOpm, Ty/BuswrsS O"rR Q Orw ATGR I MANAGER Q OTHER AuTrro=ltl)AGENT <br /> If APPLIC4NT is not the flILLJ—N—Q IRTY proof of authorixatian to sign is required Title <br /> ATJ3HQ p SLi O l. Whan 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 ENVIRONMENTAL I-IEm Tt-t DEPARTMENT as soon as it is available and at the same time it ig <br /> provided to me or my representative. <br /> 'HYPE OF SERVICE REQUESTED: <br /> COMMENTS., FEB 2 7 zoos <br /> SAN JOAQUIN CLINTy <br /> 14tNT <br /> lyr <br /> ACCEPTED BY: <br /> EMPLOYEE#; DATE: <br /> Ass1GN£D TO: EMPLOYEE#: DATE: <br /> Onto Service Completed (if already comploted)_ SERVICE:COD£: � PIE: 2,- <br /> Fee Amount: �.� Amount Paid l (� �-- Payment Qat'± <br /> Payment Type L: Invoice# Check# �"k (� b Received By, <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br />