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woa'!d6'M�/l�dttq �;ls� 'uoltawloiui avow god •�s,ues ick �eii�wx�/d IdJ �q pan!®oar seM xe; sly, .. _. . <br />SAN JOAQUIN COMM E"=IqMWTAL JDATUTHOSPARTMIM <br />} <br />SERVICE REQUEST <br />Tykeet®uahteesorF►operty -i6.r-, . I t FACtlrlitlD st:IQVIC <br />11 <br />tNblfnsatfrom!tM Adereag <br />ser. <br />e e' <br />n&vw s <br />r aTAtEO.. <br />t !. the undenlred propriv or business owner. operallor or siltharlad mgmt of same, <br />admowledp thal. all she and/or project spedfla ENviR0NmWrAL HAALTUDEPARNmr hourly chaw mocimw with this project <br />or Activity wilt be blued t0 rite or my bNaluess des Metittfied on thio form. <br />1 al:m certify thea t hmm prepared this application avid that the work to be pati timed will bre done in no0ttlame with all SAN JoAQutN <br />CnUNTY r?rdr84"ve Ca ft byctmAntr, 6TATd gnd AED9RAty,);ws <br />APPLtCArms $tGumits., �`I �G! ( DATV <br />PRorssrrl AUsdNcsstiwNBR® orutT alburm om ® OrnexAm mere umm ❑ <br />YAi,pmA Nr is not dm&jjj gFMpmfrrauAodH> @ntoafgrshepLvd Tette <br />AMR a RMBNAIM when applicalb1% T, the owner or operAtor of the property located at the <br />abova site ®therm, hereby authorize the rets of my sad ail rause:, geared oleal dela estdlor moroomentei/eito esamment <br />W01TR dOR to, the BAN JOAQUW CoUm ENv1RONMOTAL HEALTH DVA1tif4WT as $009 as It Is avolhtble and at the Inane timo it Is <br />provided to nm or my rept mentatft. <br />Tyemsta mmium : P,dp c%%nrP Z t..r. r... rtiltelt <br />10 <br />mil <br />As~tta�o ta: <br />DoW Servtee Camoleted tip simsey ee.npteaa): <br />Poo Amount: Amount Palo <br />Payment Type Invoice* <br />Check <br />Payment Crate <br />Rtr.elved <br />EHD 48-02-M 6R FORM (Golden Rod) <br />fiLV18ED 1 tltl/2t)IXt <br />m :aged urnouNun :woe j <br />