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07/17/2006 16:10 2092235044 CAL STATE ENGINEERIN n[t. EA 0 <br /> SAN JOAQUIN COUNTY ENWRONMENTAL IWEALW IMPARTWINT /3 <br /> 8d 3 a ' 1 <br /> SERVICE REQUEST <br /> FA CMY @ 0 SE)tita�a p v �7niy11�� <br /> Typo of 801ilaa or propMy 1-"- <br /> OyrRkR I OPERATOR <br /> FAcLRV NAW- > <br /> BITE ADDR68s zd Eso -7 gs63y <br /> HOPE ofVALMJWUPEM (if Dft Mfro rSlbAddroW 13 ��- <br /> STATE ZIP <br /> Gny <br /> PxanE#1 '• APNRLAna USE APPtICAMONa <br /> ( i — uZo -bZ <br /> PwtAt M rm• cos czt acT -- <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RPOIRSTOR G rPoo`,W <br /> ctaxs ntaauacAnoAot3 <br /> ®uMNM NAM T 1 $ G{ c (I T; <br /> HCeor IEARma ADDRESS FAY f <br /> E: <br /> �2� �3ro aw izrr9r zz,; - 50 �'1 <br /> -*^- , C tr 5 o h <br /> STATE -5P <br /> ITP 45647- _ <br /> 1, tic undersigned property or imsiaess owner,opersiur Or suthortmed Agent 112111:119, <br /> aclavrwledge thrt all site and/or proiect specific EWVMONMENTAL HFALTH DEPARTI 6Wr hourly charges assrtoimed with this protect <br /> or activity vA[l le billed to me or any bastmess as identified on this form. <br /> I alai oxtify that I have prepared this application and that the work to be vaned will be dons in moordaiwc with all SAN IOAQUTN <br /> CmTry Ordinance.Coder,Sraeda&,Si 7E and FEDEE&nL laws. ` <br /> APPLICANrli SIGNATURE: � Dm-t: <br /> ?F,omrvi RusrTeraowm13 OPERATOR/NKNAG= 13 o mptAOTrommAuarr l A� <br /> jf4PPLIGIM is not rAr$kt IMP-,xrr.proof qlandwriUdOff OF saga h reel&W Td[!e <br /> (�$1�A H7ON TO arT=__s c�ihTORMATION:When applicable,I,the owner or spam W of the property locked at the <br /> above site addrrsa, hereby autitor[ee the release of any and all results, gcotedutical data and/or caviro»mcmalksioe asrerstuem <br /> in furmasion to tre.SAN JOA=CD9714 Y ENVIRONMENTAL HPALTH DEPARTMENT as soon as at;s available and at the mm time it is <br /> provided to me or any representative. PAYMENT <br /> TTFr--nt SERvr:E RrQuEff S r7/1�� a j r Lez b t S v 4I. P� — <br /> iboa3rrr: <br /> JUL 17 Zoos <br /> UE <br /> ♦r o� Ns SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH <br /> \ HEALTH DEPARTMENT <br /> i <br /> Accrrrm Br; 6nPe1mEE i1: FATS: <br /> ASSIONWTo: `._ Etrx.oTEE O: FATFi: <br /> Oaott WWII:a Gwapieted (E'1lreaay I $FflYICBoxv� Sal <br /> Fee ArroOunC Anwurd Paid tk 3"7,-)-. OD Paynm d!lata -7/1-7 ( 0 (, <br /> QaynrentTyi+e tj oiroica>! Cltoel(#r 6O �Re(mivod�°� L. 7 <br /> CHH 48-02-Wi SR FORM(Gcl w R(d) <br /> ImVI.SED 1tN7r"3 <br />