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PAGE 01/02 FPI- 12/05/2008 17:@2 1209545848 OFFICE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST - <br />i>1 4- • FACILITY NAME <br />/4141 <br />DOS DisTPuCT <br />FeD)I /Of A) <br />COMMENTS: <br />t`") P S(; <br /> tios-v-o Amount Paid Payment Date PI 576 <br />Received Byt <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />CITY" <br />BILI NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ageut of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <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 />APPLICANT'S SIGNATURE: C,T —IL— DATE: <br />PaorZaTY 1 BusINv.ss OwNEm 0 OPERATOR / MANAGER El OTHER AUTHoRIZEU Aotrietr - <br />If APPLICANT is not the illlaNG PARTT, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prorpieflrety 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to mc or my representative. <br />TYPE OF SERVICE REQUESTED: , gc?4--- ave-a7ric--AcelL__ <br />.g <br />&ficall Plokin6c bitc. <br />CHECK If BILLINO ADDRESS <br />al) ) YI9 -33 <br />Err. NONE <br />(dDL(rivliy , (9- <br />thi FAA <br />(101 <br />s-rArg ZIP ctotth <br />Fee Amount: <br />Payment Type pk. <br />(6-4 <br />In_Voice <br />SAN JOAO <br />rtIVIR <br />DATE: <br />DATE: ( <br />1 P <br />JIM COUNTY <br />NMENTAL <br />,---PARTMENT <br />SR FORM (Golden Rod) <br />END 48-02-025 <br />RVISED 11/17/2003 <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (If already completed): <br />leAot <br />REC <br />DEL - <br />ENT <br />IVED <br />5 2008 <br />Check 0 <br />FACILITY ID <br /> SERVICE REQUEST ; <br />CHECK if BILLING ADDRESS <br />Toe of Business or Property <br />OWNER / OPERATOR <br />LOCATION CODE <br />--r-T2" 4- <br />Gi ZI nrio SITE ADDRESS <br />i oc). 5free't Number i motto n <br />11741'nq 7314 3. <br />tree Name <br />HOME or MAILING ADDRESS (If Oifferent from Site Address) <br />Strew Number Stryet Narnt <br />ZIP <br />LAND USE AppLICATioN <br />I31-10NE #1 <br />) <br />EXT. APN <br />PHONE #2 <br />EXT. <br />Crrt