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06/08/2004 15:30 46401:38 tavviitur49t-N l PA- r,l n rr3t al <br /> SAN J0AQ*�TV ENVIRONAI MJLL REAI - ARTMENT <br /> SERVICE REQUEST A re-(- to 1 C,c., O 2- <br /> Type <br /> Type of Business or Property FACILITY 10 M SERVICE REQUEST# <br /> GAS �t 74-TiCy�' <br /> E OWNER l OPERATOR <br /> E iss <br /> E P W CS i 00457 A20DU CTS L f-G- CKac�c tt klL t <br /> FWAMXM* A1260 4f 61 OL> <br /> srM AWIMU 6, Pq-TTE-5W PAs 5 (2oA-.D 9�3?7 <br /> 0?577j <br /> HOME or MAiLwa AoDRW Of Diffamrd from site Addruss) <br /> stmet Ntwaber Stnmd Nam <br /> CITY STATE ZIP <br /> PHM## ter. APN# ULND USE APPL►cAnON <br /> 3335 <br /> PHM02 Ea. Bos 0131 CT L.oc►naN Cosmo <br /> t <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R6QUESTDR CHaou fr D+LLtmc AOOnass❑ <br /> P. yEo2Ae-� PSE ext. <br /> eus+ Neste is 7-' 5Y5TE7LI5 0 5?�7_105fc�D <br /> FAx# <br /> ",*w ar MAUNc ADDRESS <br /> STATE ( ZP L?2- <br /> Cm <br /> Cmr ofu-A <br /> BTT I lfN ACICIyOW1.EDG,_ : I, the undersigned property or business owner, operator or Rut at w agent of same, <br /> aCimowledge that all site and/or project specific ENVMj0NMENTAL HEALTH DUART'MENNThourly charges associatedd itb this ptajcrt or <br /> activity will be billed to me or wy business as identified on this form. <br /> I also emlify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> cour ry ordinance Codes',Standards,STA'L'E and FFMERAL laws. <br /> A.PPUCANT'S SIGNATURE- P. DATE�:/ 3 �Z 3 /oSr <br /> Pftortts"!Busursa6 Owrimt(3T R/MANAGER 13OT"zR Atm+aRrun ACArrr Ca f� <br /> ecol o auagAgation to ttgn is required titer <br /> If,tPPttcalv9'is not the A�P l <br /> NVhen applicable,I, do owner or operator of the property located at t1w <br /> above me address, hareby wAhmir�e $tc releatae of any and all results, gcotecbraoal data and/or environawntal/Site aasessmUd <br /> EwVUU)iMENTAL ROAM DEPARTMENT as soon as it is available and at the sarme time it is <br /> �ptmatioa to the SAN IOAQUIN COUN Y <br /> provided to me or my representative. <br /> TYPE OF Q=%ACE REQUESTED: 'l )1 - .Sa P P ,5 F 45D2 E�L C 7 �L� vc-6 Cd2 P—WT- Z09 <br /> CoW1EtRs: <br /> EMPLOYEE : DATE. <br /> ACCEPM BY: DAw* <br /> EMPLOYEE 0: --4 <br /> ASSONEc To: 8E1tVICE COpE: P—(E. <br /> On"Service Cornpltrtod (if aireaft t0nPie"d): <br /> Amount Poid ?eymont date <br /> Fee Amount: +f ']ct. pC Received By: <br /> Check 0 <br /> Payment Type <br /> invoice# <br /> SR FORM(Golden R9d) <br />