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05402/2005 09: 51 4640138 1 ENVIRONMENTAL nTH PAGE 03 <br /> ' SAN JoA Co <br /> QI�I COUNTY ENVMONMENTlC'AL HEAL'T'H MPARTMENT –f <br /> y SERVICE REQUEST MAY 2 � <br /> Type of Ousiness or Properly FACILITY 113# EST# <br /> PERA41 fEALT8 <br /> /SER r <br /> OWriER10PE, fioR( � ` <br /> Mro,1'JG41r(IL I��,tiJr-IL ChEdKItMr INP ACJS❑ <br /> FA =NAME <br /> SrTE ADDREss1 .,3sf <br /> - <br /> Mmet N me CeAe <br /> HOW Or MAUM ADMEss-[lr DUlerent from SRe Address) <br /> ' Number e <br /> crff e '- STATEPHM#1 <br /> Zt� <br /> APS'!* LAND USE APPU CAl10N 6 <br /> 4A 1Z 3 -- <br /> 2 <br /> PHONE 92 BOS DOTAICT 1 l ocAnoN Corgi <br /> 12�t ) 23 4 i I LP ! "L <br /> CONTRACTOR SERVICE MQvESTOR <br /> RmuESTOR <br /> susiNess NAME � ' PHW7(h—3 f rh <br /> Home or MmLm Awness <br /> tq 707 G t 201) 44- G)rll5 <br /> cmr (�}�r� .ay - $TAT£ � 0)C-- <br /> PJLLR Gu l 4t�o DG : 1, the underWigned property or business earner, operator or eultborired sse:et of same, <br /> aelrnawladge that'all site and/or project specific SAL HEALTH DEPARTI+�ENT hourly associated,witti this project <br /> or activity will be billed to me or my bui iness as identified on this fform, ' <br /> I also certify that I have prepared this applieatian and&at the work to be performed will be done in accordance with oil SAN JOAQuN <br /> COQ Ordinance-Codes,Sta�rdards,STATE and FMMtAL laws. <br /> APPLICAN'T'S SIGNATURE: � ATS: JJ JJ j ; <br /> PROP=Tx/Bumq=owmmM OtSRATOR/MANAGM [3 0T=RAtmmmwAcanrr0 <br /> If APPLWAvT is not the B,, t"q PARM proof of=dwF[ZW-P t ip*n Is required Title <br /> AUT Q—%ZATION MQ L gEJ, =ATION:When applicable,I,1ho owner or operator of the property located at lite <br /> above site'address, berelsfr aE oK=W the release of any and all resuNs, geotechnical data and/or envkonrnentaYsite assessment <br /> information to the SAN JOAQUIN CoC mrT ENvM0NMDaAL HEALTH DEPARTmwT as soon as it is availabTC and at the sante time it is <br /> provided to:roe or npr representative. r� <br /> TYPFOFSM=I�QU6STED; F4.j-�—� C1= `'t.�brS1[�AC-E CO+�1�J~lq �-f rNL 4770) MEi <br /> COA11tMS: <br /> LU <br /> 3 <br /> r' `uA� 2 2 0� <br /> SAN yoA�uW <br /> • �O� -�Q i=.NViRot4tAfvALPAR iJiE1+fT , <br /> Accrzpm 13Y: O Lt Ur r /-4 ExtPLorEu#; DATE: <br /> AssiGNED T0: ([L G r n�S EMPUYeSE*: g )/ WE: �3 <br /> Date Service Completed (Ii already eompfcmd?: Same om 31S P 1 ,a3 <br /> Fee Amount: �y Amount Paid $ $� .{� (� Payment Data <br /> Payment Type Invoice# Check# / Recelvpd By. <br /> F-HO <br /> Golden 48.02-025 SR FORM <br /> REVISED 11/17/2003 ( Rod)' <br />