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Jul. 10. 2008 4: 17PM West Star Environmental, Inc. No. 9034 P. 2 <br /> c <br /> � ®tr `..L �,� UEST <br /> SERVICE REQUEST 9 <br /> Type of Business or Prop" FACU Y 10# <br /> ` Ao <br /> R I oP EAArCR CMECrc N BLUN g pstS� <br /> FAcam KME <br /> SITE ADDRESS r� zi <br /> sues twu»eee e <br /> KOMF 01 MAILING ADDREW (if of kom Site Addroull <br /> teva u st me <br /> STATE 71P <br /> CITY <br /> xcv. APN A. lawn Use/,avucAtlpN tF <br /> PHONE 91 g .AN <br /> (n) <br /> En Dos OWTI te:T l OGaTfON C4DG <br /> t > CONTRACTOR I SERVICE REQUIESTOR <br /> RE®UESTOR ® CHECK if Bit W-0A RE9 <br /> JIFAx Fir. <br /> NAmF- ,cam I f <br /> ko or M ING AOORESS <br /> ®e ' —ems <br /> �Li [D`^� y <br /> STATE� 5r € �' zip Of 137!Z�.. <br /> anent of same. <br /> 131$0 Certify that(have prepared This application aTtd that the work to be performed will be done in acc*rdanCZ with all SAN JQA(-,1.; pI <br /> COUNTY Urdinance C.®deS,Srar:dal-dy.STAT: and FFDF.s,,Ni w5. <br /> APPLWANI'S SIGNATURE <br /> PIZOFZRTY I RUSMUS OWNEA OPM-;TORf;WAGER ® OY11M Au-moviZMAGEAT Ltl�Y <br /> 1T NPPLIC 1NI'u nor rhe.0gjLyU P.SRTy,proof of aurhaH;atlon to si"n is required T111v <br /> AOTHOWATION IQ RELEASE INFORMATION; Nhe a applicable.1, Iho owner or operator of the property Iocaeed 3t tha: <br /> above: site addrta, hereby zuftrize the rcle.-asc ul any and all results. geolce:hnical data "or environmcnuslisite a.,-4e&%Tncn: <br /> information ter the SAN 3e.aAQVIN CU wry I:NVIRONIMENTAI.HEALTH DEYAK'rMENT ns soon U it is 4VaiIahlC and at the same time it i:, <br /> provided to me or my reprmijt'ltivc, <br /> TYPE OFSERVICE <br /> �RE�OUESTRU: _Y..�..r_, .^„.,^— _.. .,_....... ..._.,.._...,.,.�, ,.„._�.,.... <br /> ACCEP'fv'o BY: --'-- EMP-L YEE?1: "C1ATE <br /> ASSIGNED to: <br /> EMPLOYEE* � DArtr <br /> DatO Service COMPJ011e4 (it already completed]: _ - - SEWCE CooE:_ . ..,._...._.. E'P I Ea --- - <br /> Fee Rmounf: r ' c3i� Amount Paid DS <br /> -,-rPa ment Date . <br /> Payment YypeC,, 'T1 T - =( Check a I Received By: <br /> EHO 4W2-025 -- <br /> SI�POnM(Gutr.Ert neo j <br /> pevl5E0I11-S n <br />