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08/19/2002 12:45 46401' ENVIRONMENTAL- LTH PAGE 01 <br /> SANJUAQUI§<VUN YJANVIkLUpIM;N'iALMALTJ�1kPART1V,t r4T <br /> SERVICE REQUEST <br /> Type of Business or Property .,FACILITY ID'il SERVICE REQUEST A ' <br /> oDo185_ YW 34a8l :' :' :- <br /> OWAn0 <br /> NERIOP BATOR CHECK if SILllNe ARFMO <br /> V <br /> FAcam NAME C"— <br /> SITE ADDRESS ,YIJbr '_ e-, 0P s � <br /> 0 t Ndmbar Dili,cfio N'^� - <br /> Zia Code <br /> HoME of MAILING ADDRESS (If Different from Site Address) <br /> Stmt Number stmat M2012 <br /> CRY STATE ZIP <br /> PHONEM EXT. APN# LAND USE APPLICATION# <br /> ter egg I/ l,7 <br /> PHoK#2 BO$-Otsmtc'r' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECKIf BLLLMCADDLouaGios RESS <br /> BuSmEssNAM,_T2 'Ani l L J ` en�l. �- # $ b - 70 yO . <br /> HOME Of MAILING ADDRESS n r] (q e o - 6 9 <br /> all STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of samm. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or . <br /> `activity will be billed to we 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 JoAQtn <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL laws. t <br /> APPLICA.'JC'SSIGNATURE:��L IYI—UYl V J� DATE; 6 <br /> PROPCRTY/BOSINMOWNER❑ OPERATOR/MANAGER El PER Auomimn AGENT 11 <br /> IfAPPLicmrfs not theBb9dap AR7Y.proof of authorization to Sign is re4uired Title <br /> AUM)IM&TWN TO RELEASE INFORMATION:When 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 JoA"COUNTY ENvrRoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it s <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: UST lzeneo F IT,IPAYMENT <br /> i <br /> Coasears: RECEIVED <br /> JUN.3 0 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLICO HEALTH ERROCES <br /> WARONMENTAL HEALTH DIVISION <br /> APPROVEO BY' �- <br /> ,,.. <br /> EMPLOYEE III: DATE <br /> ASS1GNm 70: EMPi.OYEE#: r - <br /> DateService'Completed (If al dY platod): ` SeRVKECoOE: ' $ P/E " 'a . <br /> Fee Amount .(pd0: = Amount Paid .?..000 Payment DateQVJ . <br /> Payment Type Involce# ''_ Check 9'.2 2- <br /> EHO 48.01-025 SERVICE RE•QUESTWORM <br /> REVISED 6-5-02 <br />