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FROM :.Don :. ee au nig Co. <br />FAX NO. :2095379398 - u 1. 17 2006 02: 52Pi1 �::._ <br />SAl'i JOAQUIN C:OUIN'i'Y ENVIRONMYNTAL HEAUI' 1 1PF PARTME1`47 <br />SERVICE REQUEST <br />Type of EUlint-ls or Property FACILrrY ID # S: ICE REQUEST # <br />M4 - <br />64 <br />OWN'_R! OPERATOR —L.4t111¢[ ,0 <br />SITE; ADDRESS <br />SS <br />&tr920um�7 llr�tlon J .... St Neme ��:.--,-- <br />IHOME! or I�,41LI�H JtiDPRFSa (If DifforDnit from 55 -lite Address)��, <br />umber I [i a -act ►lame..— <br />CI"Y STATE Z1P . <br />EXT. APN it LAND USE.APPucATl0N 0 <br />PiinroE #2 <br />EXT. BOS 013-nICT Z, t ocaTloN CO <br />rte.-►irmn A rilllInD t c'r1DvT("r R �B 11 1 Ly.fi'N'11T� <br />RE-QUESTOR <br />E3L'SINESs NARIF <br />HOME. or k IUN-0 <br />Cr:"Y <br />��^ CNECK if ®ILLI <br />EMT. <br />F,ic# <br />STATE :. /P_ 7'P -'> <br />l�allolC: A�_ tN®i?VLFiD FIS ,,'J: 1, Ole undersigned property or busilless owner, operator or authorized agent of same, <br />acicnovilodgc tht all site and/or pmjec" .^,pecific ENVIROWLN'1'AL HEAL'111 I)f.rARTMENT hourly charges assooiated with this ;)rcic(;t <br />or ac-:ivity will ",)e billed to Inc or my business as identified on this form. <br />I z[so certify ':ha: l havo p-xp and Lbi� application mid that the work to be perfu-nidi will be done in acco •dr^nce with all SAN JCA UIN <br />CUU`�Ty GrYtlnaerc:cr ('ry e, , .S'danr ttrdr. yrrcr� d Ll r <br />A PP LI'C:ANT'5 SIGNATURE; �'' A ---r ' DA'i'U: 1�.'17 xel�k-_. _ <br />PAOFCRTY I fitOwrq; 0rrR,iTOR / MA2+ACER ❑ U rtiMR A(1TIinR17.F,D AliT.V7� si zr� C�J _ _ <br />Ilj APPLI(:ANT iy n-.11 the f'1uZyCcj RTY proof of autharization to %Igm b required Title <br />A j J; 1jjZA, TCFPi Tip :.�E I-j;�j�ATI N: When applicable, I, the owner or operator of the property locates at the <br />c�l:mv tate sttiriress, hereby authorize tie release c: any and all romfts, geotechnical datZ and/or errvFonrnc:ntai,'sk mscs:rncnt <br />iti1.'9trilatioli to rhe SAN JOA.Qt]IN 'C-OLN'ry E•NVIRONMliNTAL I IrinI.T11 [TRPAr'�TrVIENT as soon as it is avnila leewid at the same ti)l. is <br />,I—L-1-4 to — rr my rmnrFu nfsr•ivc. H `'(I V1i=r\rr" <br />Ty:,E ol; SERVICE RE=STED: - - <br />V Q <br />CONNI-iTS: <br />JUL 17 Zoos <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACcF.PTRD BY: <br />EMPLOYEE #: <br />� � D4TE: <br />AsstoNEDTo: <br />EMPLOYEE#: <br />3S �-� WTE: 11111 Xt <br />Date Service C:ampleted (if already Completed); <br />SERVICE <br />CODE: P1E <br />Fee Amount- <br />dirr,ouei Paid <br />Payment Date <br />Payment Type �/ <br />Invoice #C <br />heck <br />CD (] <br />RacFiwad Ey: <br />r --HO 918-02-t125 SR FORIA (Goldur 11ai) <br />REVISED 1'•/1i/i_L03 <br />