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JAN. 31. 2006 9: 33A&NJGCEIN_E_31CO�WVEN N0. 466. P. 2 P- a <br /> V[RONMENTAL 1�tL'1'FI DEI'ARTM$NT <br /> Type of Business or Property SE,RVICIr REQUEST <br /> FACILITY IlD K SERVICE REgUEST N <br /> OWNER! OPER OR Ob � <br /> FAvVrY,,,NAME /1 <br /> y e- CHECK i/, uAq gpD�p <br /> 'TEAODR as <br /> elo,1 s (If <br /> HOME or MAIIINC AnDRES$ (If DiHerenl!rom Sile Si e <br /> godros5) it I <br /> Er COIIC <br /> CITY Spee Nvmeer <br /> a e <br /> PIIONENISTATE 21P .— <br /> EXT. r <br /> 'w" LAND UsE APPLKgTIDN K <br /> PHONE N2 <br /> BOS O16TAICT <br /> LOGT,ON CODE <br /> REOUESTO CONTRACTOR /SERVICrs REQZIESTOR <br /> USINESs NAME _ CHECH IT L <br /> He ADDRE GAOoat;S ❑ <br /> MEprM PHONEN Ear, <br /> COTO� Full Y <br /> STATE�,A^ ) ZIP <br /> Itl ,iNC ACI:N We anw .Moja 1, Ih0 ondeisigned property or business DTnter,, operrator or Authorized agrut aT scone, <br /> oC'koDlvw will <br /> that le site is 0, project spceiGc CNVIRONMENTAL IiEALT1'1 DEPARTM771T'hotll'1 CBa 1 <br /> activity will be billed to nlr Gr my business as identified On this Foml. <br /> Y YgOs assucinlcd with Ihis pruj cel nr <br /> 1 ,iso I'Y 01y dwl I have prepamd Ihis application and lhst Ih work m be performed will he done ill Decordmlce w1111 all SAN 1OApuln <br /> //' CUVNI'Y 0lvbunlrre Colles.Srendard+'. ' IE and -Wr•� 1, ws_ <br /> x PPIACANT'S SIGNATURE: <br /> E ` Puureinv/DuslNti.ow"rnQ DATr.: <br /> O"11ATOlt/MANACEII ❑ Orimit AVTuoA1ZE0 AGrATQ <br /> 1fdR/II,ICAN7'1Y 110,rile ! .IN 'P lll'Y <br /> A ITIi'O12-A'19oN TO RrI,FA F. fNROR AT P, Ofarldurrizafion lu s(Rfr is moirrrl <br /> ON: Wlten Dpplicablc, I Tldr <br /> abore site adflress, hereby oulhorize the release-or Dns and all rcsuL's, gcoht bnicalr data and7oroperator rnvironmental/site alled cnl <br /> IldOrmalioll to 1110 SAN JOA UIN of O sWcper1S, Iota left DI the <br /> Q CDUN'1'Y'C7NVIItpNM1iN'I'dl.E`t ALTl1 DO"ARTMEW IS soon aK 11 is uVailalDle and3t [Ile same time it is <br /> provided to ntc or my representative, <br /> TYPE OF SEAVICE REQUESTED; <br /> COMMENTS: �`— <br /> B 0 2 Zoo <br /> SAN UOA 6 1 <br /> QU/N COU <br /> HfALTry Wy <br /> pE ARNTryAL <br /> APPRDv�o ar; <br /> NP <br /> EMPLOYEE K: �Y,(1T Z 2 <br /> �AS3IGNED TO: DATE: <br /> Date Se1 Completed 111ralfbadr Gompteteo);- .EMPLOYEE/. DATE•. / <br /> Pea Amount $ERVIDECoot: PIE, -,-)b) <br /> Amount Paid acs <br /> Payment Typo �/ a��• � Payntont Oate <br /> Invoice K Citaek K I <br /> Z 1 <br /> E1+0 a8-01-025 Received Ely; ti(71 <br /> REVISED G-!-02 <br /> SERVICE REQUEST FORM <br />