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27. 2005 10:50AM No. 29€7 <br /> SAN JIDAQi"i f'COUNTY JJEN VIRCIMRENTAL 13EALTH ARTNMI?,1rT <br /> SERVICE REQUEST <br /> 1W,o!P BusiBuei nes; or Property <br /> FACIUCTY ID# SERVICE li <br /> a'6�1�x� TAtL. fcoCl 26= It <br /> ()Y1fN1EFt f RATOt{ Gr�cx M 6 Ni Aon <br /> 14,06 <br /> city <br /> 3lreetN.:.:' <br /> LW L <br /> DRES- <br /> HOME or MNL Itlti ADDRESS (it Di Went fM Sk*Address) 5,11 gj, <br /> street Number ---- <br /> BTATE Zll� 1 <br /> Crn <br /> PMt�;e II; EXT. AP / LAND USE#kF'PLIcATlON <br /> Pw*E92 EXT SO'S DISTRtaT� Lacaxrww Ccx+� <br /> CONTRACTOR/ SERVICE REQYUEST(M <br /> P.EQUF$TOFL�� �- - c,�rfi1C ff BILLING Age{�' <br /> PHONE$ <br /> E3 SIMEw N)Wxt_ <br /> Home(]rmAaLlNe ADDRESS FAx9 <br /> Ald <br /> STATE <- <br /> I, <br /> wI, the undersigned property or buiness owner, operatDr or authorized agsnt of s me <br /> aclmoFviedge E,at all site and/or proicct specific ENV RONNib1,7AL HEALTH DEpARI-NogT hourly charges associated-W, this )+r-beet <br /> or a-.fvit}' A ill b•3 billcd to we or,.my bu3i ess as identified on this form. <br /> I also certii?t tiz,I have prepared this application and that the work to be performed will f)e done it accordartoe with alL SAN TO.A,,TJ1N <br /> COUNTY Urdis&rce Codes,a"tandi <br /> A and FMERAL1aW3. <br /> AI PLXCANT"S SIGNATURE- DAIE: <br /> PR0MTyIBvuNm rx 13RATOR _ -AGER © pTrxr Atrtta(orct oAGEDr <br /> 1�dPP1JCANT is not the MA Q,PAR1 P proof of authorizadon to sign is required : itt e <br /> ptu__Opjz q,X° ONTOLEASE INFOILMATIOM When applicable,I,the owneror operator of the property.00 fed G t the <br /> above site address, :hereby authorize the release of any and all results, geotechnical data and/or envuoncsental/sit•: aswsment <br /> infbrnaLon tic c SAV TOAQUQ+1'COUNi7 ENVtR©NMENTAL HF-ALTH DEPARTKM aS Soon as et is a ailable and at the&xnC tithe it is <br /> proAded to the Cr my representative_ <br /> TY,3' of SMICE REQUESTED: x j' <br /> JUN 2 7 2006 <br /> SAN JC),"IQUIT'l C0UM_r1( <br /> ENVIRONMENTAL <br /> LTH L?EPARTMENT <br /> AU EnTEo BY: EmpLmr:#: DATE: <br /> r <br /> r!I<<ifsliED TL+; EMPLOYEE*: DATE' <br /> Mte Service(kimpleted (It atraady eoir,pleted): SERVICE COW. PIE: <br /> Fee Mo t o Amount Paid $s l(lg, (aY�T�errt Data �l}� 6 <br /> Psrrte I nvole'a# Ctrank A X11 Q �'7 Recsd 8 <br /> EHD 4"2-025 5-1F ( Rod) <br /> REVISED t1;'1712DW <br />