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bAN JOAQUIN UOUN-IN I NV1NUNMEN'1'AL11 9AL'lE'H JI3LYAK'1'MZN'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER 1 OPERATOR <br /> ?W%L- H E!V hip <br /> -4 CHECK If BlUiNG ADORM-13 <br /> FAcx;TyNANE t INTP1 <br /> STrE ADDRESS ry..}(�r,0 irV1 "<X V I LLE (� . <br /> c�� <br /> sum Num6cr c <br /> ftME or MAtm ADDREss IN Dltferent from sae Address) 1 aZ7 tf cpj W <br /> street Number b <br /> Crn S fty.) "ISI Or.! STATE C-A <br /> Exr. LAND USE APPUCAMON <br /> 61 S�&- (019 ozl - Iso-o8 , -� Pp�-IIovo5(p <br /> PHDNE#1 Im DMTRICT Lot:A'TM CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQtlESTOR <br /> PSS 13 Y pk CX-0 crreac it BiuUra?Aa��ss❑ <br /> BuswEss NAmE L I J aR1� G NiJ1 I�anJi'�1EN Tpt q# 3inr1- 01"17 <br /> EXT. <br /> Home Or MAILma ADDRESS FAX# <br /> * tN a#t1= STT• (Zv <br /> Crrr Lor=' STATE c-A 7aP g is'X+Fo <br /> BlUING ACIJNOWLEDGI I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and th the work to be performed will be done in accordance with all SAN 1oAQurN <br /> CouNTY Ordinance Codes,Standards,STME and FED laws, <br /> APPLICANT'S SIGNATURE: a-11'fV-9Zi:i 46 DATE: ZO <br /> PROPERTY/I3115rNES5 OWNER OPERATOR I MANAG 13OTHERAUTHORIZED AGENT❑ <br /> IfAPPt.1CANT is not the��k wG P�trrT pr f of authorization to sign is'Wuiread ri=te <br /> A A E IN TI : When applicable,L the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN)6K(-4L i C609TY EiMRONMENTAG HEAGTH'Di�PARTMENT'as soon gs"it-is availatSle-and-at the-Same-time it is- <br /> provided to me or my representative. <br /> TYPE OFSERVCE REQUESTED: (-=;all EVOI Stsl L Sv 1Tr1t31 t~I T� S'��y <br /> Co"affs. SCD (( RECEIVED <br /> 125741-2719aJ&.� d -rte, JUN 2 9 2411 <br /> Cil-�-'SSP- & <br /> SAN 30AQl51N GOl1NTY <br /> ENV4FiONMP-N-T ENT <br /> HEAI-�DEPP.FIl M <br /> ACCEPTED EmCLOYEE#: Y DATE: <br /> AsS GmED Ta: { EmPLOYEE P. 5'(�tf DATE: <br /> Date Service Completed (if already completed): SM=CM: �r�j P 1 E: <br /> Fee Amount: aLfjArnount Paid ffi Zqy D Z) payment Date 4v ; q <br /> Payment Type Imroice# Check# I s Received By: <br /> EHD 48-02-025 SR FORM(Golden It/od) <br /> REVISED 71/17/2003 <br />