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Jul, 06 2010 9: 07AM RSERJET FHX . p, 2 <br /> 09/09/2001A VIC 11:02 FAa 2o91f93433 SJC PHO --- Shockhon Sexy Sea 3q Co fiD00./Odb <br /> SAN JOAQUIN COUNTY ENYIRONMLNTAL HEALTH DEPAHTMFNT <br /> SERVICE REQUEST <br /> Type 0$UshieesatProperty FACILPIDN nlimIGRR-EQUE I <br /> 3 "0&0 <br /> lOPE1EAT j� <br /> FAoorNAMF,� _ \ <br /> SITF A00AHS <br /> t 2i C t <br /> ROhEcr MALw3ADDRE95 OE011PorDnt Nom else Address) <br /> r�N N, JfSLNC]L.... <br /> CITr STATC Zip <br /> PNDvp 91 <br /> ell , APNA ytAO ULC AontivtiOwY <br /> 1 I <br /> PMeNF E2 Ert, BD9 OHTNOT „oOATMN OOOC <br /> CONTRACTOR I SERVICE;RE UESTOR <br /> REQUE97011 CNEGN I7 BLLINO AWRU35 0 <br /> M I rrr Ft ou-c <br /> BuFtNeu NAMq v�ER PxoAE1 e'r. <br /> H0M6 or MAILING ADDRIFSS FAIL tl <br /> - <br /> CiTY SrAre Le <br /> DI LLI NG 6"NOW LE DQ LM IENT, 1, the uncl ersigned propArey or bUElnpa owner,opt n%or Or autIto rlud Agony Of Arms, <br /> t eltrow l edge(hat ell Ei le andror pro)eel Spee ifc ENV IRONMCNVTAL WA 1.H OSPn RTMENT hourly Charges Assoc haled will In(his pinlect <br /> at Activity Will be billed to me or my buslneo na idcmifred on this form. <br /> 1 5159 eeytify dsnt I hove prepared Ihis Appliuclon end that The work to be tx:rfonnDO will be done in accordance with nil SAN JOAQUIN <br /> CnuNAY Ordiponre Ceder,Standards,STATE end PEDERAI.NV. <br /> APPIACAW'S SIGNATURE; DATE: -7_��/OT' <br /> PPOMmTYI BUSIME31 OWPAo❑ 41KATORI 1YAORN❑ OTlleit AuTlice¢aD AGENT❑ _ <br /> 1fAVIUGN7knor Ute Bl- Ah pws7z prod/d�anlGorkAllae lO alQA la rcyntraP lab <br /> ALITH0RIZA,n0NT0 RRLEA9E INFORMATION:When applicable, 1,the owneror opuatnradle property localcd aI the <br /> above site Address, hereby ooUmri2c the release of any end All results, Eooleehnicnl data anNor enviro inmtthili aucurnent <br /> Information t0 the SAN 10AQUN COU147Y ENVIRONMPNTALNtAL714121CPARTMENT eF war as II it available and eat the same tinge it i5 <br /> provided to me or my representmive. <br /> TYPEOP SERVICE REQUESTED: b6T 172VFI-F PAY <br /> COANCN7l: <br /> JUL - 6 2010 <br /> SAN OUN <br /> EONMEN <br /> NVIRTAL <br /> FiFJ�I-TM DEPAFITME.N <br /> AGC tMIs BY: DATE: <br /> EYI'ATCC d: Ifl <br /> 7 6 <br /> A9SIONEp TO' D � EMPLOYEE a; DATE: b <br /> Date SDrv'reo Completed (11 Mrtvwy tDM0011d): Susvice doot <br /> FIG Ardoun0 ) _ o Amount Paid Payment Dole gUnD <br /> Payment Type / Invoiced CMcNM >, 1,03 \ Received By: rf-r,- <br /> EHU 19.02-025 SR FORM(0olur Rot) <br /> A NVIGFG/1117,2007 <br />