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Feb 25 03 O1s37p AG SPANOS JET <br /> CENTER (209) 983-4710 <br /> FE8 24 2003 3: 00PM 4WCO A• 3, <br /> ' ,C; 2094G*49 <br /> p. 2 <br /> SAN JOAQUIN COUNTY <br /> hYl1ZONML RLAI,iTi ll !'A!Z'!'NIis1ti'1' <br /> Type of.8usingjs or Property SERVICE REQUEST" <br /> � FACIt.fTY to 1 <br /> SERVI(,E REQUEST Y <br /> I(1WNEA <br /> fl PEA!{TDR <br /> FAU,lT'Y i~fAlrtECHEcr<:!81L LING A <br /> AES <br /> $(TEA�QUREESS <br /> V <br /> I ! U V L✓ <br /> �iDMt Of MAIUNG ADDRESScl Harms <br /> (If 0tlfcicnl from Sllo Address) <br /> II <br /> CI! <br /> ri C4r! <br /> Iry <br /> Ir pl NunDtr <br /> f Na <br /> �Af�+DHE YS . STATE zip <br /> etr. <br /> ) APN M <br /> r - <br /> HE A2 Ear. l.Mr+D USE APPLICATION# <br /> � <br /> f ) <br /> DOS DISTRICT I.DCnIIvH Goo[ <br /> [GUES'MR NT CTO SERVICE <br /> RI✓QUESTOR <br /> LISINESS NAMECHrCrrlf8llUu�R£SS❑ <br /> ' "t <br /> CME or MAILI G.ADD�ESS PHDHE ti -s EXT. <br /> t 6 F— c�33 <br /> FAX 8. <br /> ILL[ A STATE <br /> IWl E!� '.'rNT: 1, OIC t+ndCr5l�fled l)rOiTCTI � 21P � fJ J <br /> N1 knowledge that all site and/or pro JC spcciGe EldyHtoNns y or busilress owner, aperator or aultre,rized n sal++c.. <br /> A�fivity will be billed to me or Illy business as idenli,�u3 pn�?AL HrA[.1T1 DEPARTMENT hourly CllargeS assns,. 1lis Df <br /> f his farm. lalccf willti lllrS Prvjccl or <br /> also certiry that l have PrcPared this apirlieation and tltat the work to be per(ormcti will l�do+Ie <br /> OUrfi}'Qrdulorlcc Cortes, rn accordance,with all SAN 10AtlUIN <br /> s,ASTAT- 11MRA[,laws.Itir'P1.tCANT'SSIGNATU24 <br /> '�IorNHrvllt +slY+SsOwnLRDhTli:OANACER ❑ arilenAurltorur,u,�C 0 <br /> 1/ArruCrfrrrir rlor rlae(3r f <br /> i' 1TH R 17,hTt lV T —�-��PArr7.r.proof of nurlrorizaliau!o ri�N r3 req+tired <br /> lief C� 1rYCQFi T[ Iirle <br /> A Ove site address, lureby authorize the release or any and all results, gcatechnicol d,ta and/or cnviromnarta[rsirc asscssrn <br /> hell aPplicablc, 1. the Owner or operator of the pt•operry lor;llcd at Il,e <br /> Wormalion ID the SAN J0AQU1,� <br /> COUNTY 1 YrRONMENTALJ-1L'At71i DeP�RTMENT'as soon as it is available anll at Il�c same time it is <br /> Dvidcd to me or my rcprescnta[ire. cot <br /> ?E OF SEFYICE R!pUESTED; <br /> PROVED 9T: <br /> PZIUVED 70: EMPLDYEE 0: <br /> D,ttE: <br /> i3ic 5crricc CarrJpiolcd {ir nlrc�gYeomPielgd); EMPLOYEE A: DATE: <br /> �o Amount: ASERVICE Cooc <br /> mvunl Paid <br /> �yment Type Paymant Date <br /> tnvOice✓V <br /> Chock a <br /> o 43-0+-025 Receival By, <br /> 1 L+Y+SED 6-5.02 . <br /> 1 r 'zERVICE REQUES7r--0nM <br />