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• r, "605/27/2001 13:57 2094683 FIFTH FLOOR PAGE 05 <br /> SSMAC5 REQUEST o O o?to la <br /> Type of Business or Property FACIUCY 0# • I. SERVICE REQUEST R <br /> (104`1 '� 1 <br /> OWNER OPERATOR $ILLIHG PARTY D <br /> a U I k's-t-0 MAez&I-5 , I dC. <br /> FACamNAME �j U I IZSTnP I'iAP-Lb3 # 1214 <br /> 5tTEACORESS .ra en orr,�x, tel. MAIM <br /> sen.e r+� Tr9. suite e <br /> Mailing Address (lf Different from Site Address <br /> CITY ILII A-AI TSCA- STATE eA ZIP q63.3(. <br /> PHOYE91 t APN# LmDLrSEAPPLrATIcN# <br /> PxoNE�2 �'- SOSDtsTwCT '- Lo7N.CooB.• . .- <br /> >, �. <br /> CONTRACTOR I SERVICE REOUESTOR <br /> BI <br /> UM <br /> rs <br /> p.D. y�21� 6 UxG PAPAM❑ <br /> BusLvEss NaaE <br /> P <br /> HONE 4 Em <br /> T TZ l�.1 cry 6,.1�I R-o�1 H 6,cTA� , x�tG <br /> MAILING Awft4ssFOX <br /> 2 S 25 I3 u 28 }x1 JZ ,81_Jb . <br /> sraTE L'A ZAP Q r SoS <br /> Crrr 3uQBA-rlK , " - <br /> BILLING ACKNOWLEDGEMENT:L the undersigned property or business owner,operator or authorized agent of same.adv*w!e ge Plat all s�W andfor prgjec-sped <br /> PLsuc HFJILTH S vfCES ENv RCNhrBdTAL HEALTH ONtS oN houdy charges assoaated with Ihis pmied or acdvdy wilt be biled to me er my business as identiEed on this`arm. <br /> I eta cerdfy that I have prepar*d this app(ira6 and that the work to be perromred-NO be done in aaadance wah all SAN Jt AMIN Cawjy Grdinz=Gcdes,Standards.STATE and <br /> FE0E4AL ISM. <br /> APPUCANTSIcvATUPE: CDATE: IO "2 <br /> FPOP SNIBUSNEssOWNE3 ❑ OPERATOR/NiAltkGER 13 OTH :FzAUTHOR=AGENr ❑ ADM IPdIS—,rA 7-c2— <br /> f;ApPLcAx7 is rnt8u S.Lncc➢Tar+.proof d=61ori:ation to siSN E tr rirvd ri rte <br /> AMATION:When appEeabte,1.the owner or operator of the property locaMd ai tite above sae address,hereby authorize the refeasta of <br /> arty and all results,geotechnical dam and/or erMronmeimllsite ame�eoj Information to the SAN JcAmLs GamTY lPta C XE;kLTN SarzvM ErMROrauIIrTAL HEALTH 0MSloN as soon <br /> as itis available and at the same ftm d is provided tome cr my represarmtivve. <br /> TYPE OFSeZVICEReau,sren: <br /> CoM hlEv;s: • <br /> PAYMENT <br /> RECEIVED <br /> JUL 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC kIEALTH SERVICES <br /> ENVIRONMENT" u�,.,;T,, ;,,,;,N <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SrMTURE: <br /> ArPQm <br /> OVBY: lSGPt^Y�'tl". I DATE, <br /> Ci <br /> Ass>GNEa T0: <br /> i - EMPLOY=- EED)ATF- <br /> ;,Z�Date Seryice Compiet (if already completed): e .: { P I Z3C� <br /> Fee AmountAmount Paid 7, Payment Date� '. <br /> Payment Type <br /> Invoice a,', Chezlt /�',:� <br /> Received By: <br />