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04/27/2016 12:17 209239470 SAVE Ott 6AS & LIOLIa2 PNCE lirave <br /> SAN JOAQUj N COIINWF-WMONM NTA1,HEALTH DEPART'MNT �.7�0 APR 2 7 2016 <br /> SERVICE REQUEST d��" - �r1 ��PE p i <br /> i� <br /> Type of BuslntNsss o rr FACIIM D/ SERVICE REQUE67 A ;— <br /> s <br /> OWNER/OPERATOR CI,ECKRB6LIND ReaS❑ <br /> FACiLm We <br /> SITFADFSS Li:w �F/• Yu Sar^"1� o,Je Mc,v. CA GS33 a <br /> DR <br /> xvam.. <br /> HDt1E or NAEING AqPESS (x oifferera Fran SRO Addreaa) &Ylx CIO, $a- <br /> 3 ./ <br /> Cm' STATE TIP <br /> phMil M. APR L.ANo Use APPOCATioN0 <br /> ISIo > -71-A V\11 <br /> p E Bn. 136-3 RKT LocAr"COM <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQOESTOR CI ECXII @aLINDAabaess <br /> PxaxER <br /> BVSINES9 NAME awc O� �� r✓ 's� 1 73 '� <br /> Home or MAuNG ADDRESS Ful <br /> CITY STATE LP <br /> IST JNQ ACIQNQWI.ED( 1, the underoigeed preperb or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific awmONho TrAL HEALTH DEFAR.TmxNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the woik to be performed will be done in accordance with all SAN loAQua; <br /> CouNtr Ordinance Codes,StandarAa,STATE and FEDERAL laws. <br /> APPLICANVSMGNATI(119� DATE: 7L" <br /> PAOFRRTY/RMoM()WK1#P orERATeeimAnArrARR❑ OTHUMAOIHORIMAGANT❑ <br /> JfAFPUCJNTis not the fig gPAk71:proofVf anthorigodon W sign&required Title <br /> A7J3MQRI4.UM �f!XA.etc T f_QA M&M.-When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby autborize the release of any and all results, geotcobnical data and/or coviroamentaValte assessment <br /> information to the SAN 10AQUAI COUNTY ENVIRONMENTAL HEALTH I)BPAE,TNENT ee noon as it is available and at the name time it is <br /> provided to me or my tepresentativo. P/� <br /> TYPE DF Seswer REQUESTED: u sA— fzmtx•Ey+_ RECEIVED <br /> COWENTe: 1dc?.I 1� C Myq PR 19 206 <br /> SAN JOAOUlm ca[wn <br /> ENVIROWNTAL <br /> HEALTH DEPARIJI&W <br /> AcrAPrsD Br: EIWLOYEE#-. DAZE; <br /> ASSIONIM TO: - FAPLOYEetl: DAM: 4 '-Ar\rr, <br /> Date Service Completed (it already coeplstsd): "Wecow 5�1°I$ PIE: Z ND <br /> Fee Amount: 4 ND-W Amount Paid 3 CT e. CPO Payment Dale Yll,,h - <br /> Payment Type C V_ Involce f Check N Re d 8y: <br /> EHD 4"2-025 SR FORM(Golden Rol) <br /> REVISED 1111MD03 <br />