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12/09/2003 15: 69 9252836P'S DESIGNERS COLLEr-'VE PAGE 02 <br /> 16/30/2003 11:41. 20946834, FIFTH FLOOR PAGE 10 <br /> oPkrrJUAQULN V.uU1vTYENYMONNZriTALHEALTH DEPARTM, n <br /> SERVICE REQUEST <br /> Type of Business or Pn4xnly 11 FACII l YJD,9 SERVICE REQUEST-P <br /> OWNER OPERATOR �� htvi I .-," "J SSS hi( /�li'- .(,4)-v /!/Y f� CHECK to sR <br /> FAC4rrr NAIVE �L�G�_ G/�'fI'�1'��'1 J TLI�D l� <br /> HOME or MAtI. G ADO Ms (If Different from Site Addre") 41�J <br /> N <br /> (:.fTY STATE ^ 'w Z]PPHO <br /> 1 'PM 91 ?a I APN iM LAND USE APPLICATION 9 <br /> 1 2 -O d-D.3 <br /> PHOK 9Z T- BOS DibTivci LOCa7i0ri CGDE <br /> ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RettuEsrolx Ov& 2s�, I bkzlA//11 CHECK If B1LLL7g%8pA=g❑ <br /> aLmiNM NAMIK fit~S'I /lPrY l i a 20 5-3b 3 13 <br /> HofAtEyr M o Af�gRE[/I / / ������ Q r /r�� LW7V617-�, <br /> STAT: ZIP <br /> 13U,L `1G ACWQWX.,E EMEn. 1, the undersigned property yr busintss awner, operator or authorized agent of same, <br /> ac)M0wle(%e that all sitz AtNor project specific Errvtk0NM9NTAL Hirt►DtrPARTMENT hourly cbaxges associated with this project or <br /> activity will be billed to me or ary buetness as identified oz this£o=L <br /> I also certify$tat I have prepared this application ead that the work to be performed will be doge iu accordance with all SAN TaA.Qutnt <br /> COUNTY Ordinance Coder,Srunderdt,SrATz and FBDEP-^L laws, <br /> A,PPUCANrS SIGNATURE: ,.. DATE.- �Z"/�� <br /> PROPMTY/Fit19t`M 0wKX4 Orew,TOR l M,0A0ER ❑ OrHER AuTmogiZLD AGEINTO <br /> IfhIPPLICANT is not the BILLING proof ojauthorkation to sign if required 71r1c <br /> AUTHOMZATION TO 1REf EASE O1FORMA 011f; When applicable,1,the owner or operator of the property located at the <br /> above site address, hereby auktt rize the rtIcase of any and all results, geotechuieaI data and/or envirorwiental/site asscssment <br /> Mfozmatiotl t0 the SAN JOAQUW COUNTY ENVIRONMENTAL HFau_rx DBPARTMCVT as soon as xt is avallable and at dte.same time it is <br /> provided to me or my represmiativc. <br /> TYPE OF SeRw-F RFcmr: ED: <br /> CaunrEnTs: <br /> APPROVED BY. EMPLOYEE#: DATE: <br /> ASSIGNEP TO: EMPLOYEE/k: DATE: <br /> Vote Sar+rica Completed (if alretdy Comm pleted): SERresCOFI PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check r Received gy. <br /> RHO 0-07-D25 SERVICE REQUEST FORM <br /> RWSED 6.5-02 <br />