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OCT-26-2010 12:101'M FROM- +8266!17885 7-167 P.002 F-408 <br /> r' <br /> SAti JOAQC!)<111 COUNTY ENVIRONMENTAL HEALTH DYCPARTMENT <br /> SERVICE:REQUEST <br /> Type of Business or Property FACILITY 1D p SERVICE REQUIMT# <br /> OWNERIOPERATDR - —E/vT' GnE CKSILLKSADDRE55L <br /> K�ISfsR 'PERN►•kN � <br /> FAatm NAVE <br /> SITEADDREss <br /> ,�� + StiaeNu.b�r biwetlen '�+��Bae1r .6".;w��}� Gode <br /> MML'tfr MAIING ADDRESS (If Different from site dress) <br /> suenetmmb.r <br /> CRY STATE ZIP <br /> PHOIIs#1 CKT• APN6 LARcliarAPPLICATIom0 <br /> 1 _—_---- —_ 12,o <br /> PHO11E02 sOB WIN= LWArM GO= <br /> CONTPACTOR/SERVICE REQUESTOR <br /> RWX MSTQR <br /> owaro if_SILLWr Acba <br /> Baa L hilres~w+ \.r+ -�+ *e. P # -n SIM as <br /> t ori umaAnomas FAX# <br /> .. y <br /> $TAtiE TJP 1#I <br /> GEMENT 1.the ucdcrAgncd proporty or businesr owners operator or authorized agent of same, <br /> acJaiMedge that all site and/or project specific ENVIRONMENTAL 14mTH DEPARTMENT hourly charges associated with this project <br /> Or activity will be biltrd to dro or my business as idenff=d an this form. <br /> I also certify that I have pttelftu'rd this application and that the wodc to be performed will be done to accordance with all SAN JOAgum <br /> COUt41 Y t7rd!►ncmce Coda*,Standara'sj TaTE and Yaws. ; <br /> APPLICANT'S SIGNATURI. �� AAT i <br /> PnomRTy t vusmss owrtsa[3 OPERATOW MANAGER OTRRR AUTNOR=D AGRNT 1R <br /> yAAP"c-4 T b ROt the RJIJJN-C 818 Y xi—f of elllAorkafien b skn is r'Mtr#'ed rale <br /> AIaTI Q1iYZAT RELEASE p"R& <br /> I&UM:When applicable,I,the 6wher or operator of the property to=ed at the <br /> above site address, hereby atlthorin the release of any and all roaulW, geotechnical data and/or envimumentaUsite assessmedt <br /> information to the SAN JOAQUIN COUNTY ENVIMMMITAL HCALTH DEPARTMENT as soon as it is available and at the same time it is ` <br /> pievood to me or my representadve. i <br /> TYPEAFSERVICE RERYIw1w: L4-s"rMwe Nap-w <br /> Cotsitarta: - - <br /> REC'W-L <br /> SEP 13 2010 <br /> SAW 4CAQUIN COUNTY <br /> LDAF-HETH EPRTMNT <br /> ACCEPTED BY. EIMPLOYEE 9: ��� DATE: � h <br /> ASSIGt�b ro: <br /> Lam— <br /> iPIAYEE ,rtiFb DAT <br /> s <br /> t?atu Service Completed Of airsady completed): S1 mi cam: P i ' G <br /> Fee Amourm Amount RAIdPayment Date <br /> PW=ntType Invoice Check"'Al 0 ew Re elvad y". <br /> EMD 4&M-02SSR FORM(Golden Red) <br /> EVIS�D <br /> RL1 111t1/t712{>09 <br /> LZ /Z # Z096L999166 L9:91 !04-6Z-N <br /> ONI S31VI30SSV 3d(lVd Z09IL989T61 06:60 0TOZ/6Z/0I G3A1303H <br />