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SAN J0AQ'qC0UNrY ENVIRONNUMALlir TNIENT <br /> ` T <br /> Basiness or.Propoty y FACKM ID# SERVICE REQUEST/ <br /> 3,7d-7 5 4o 31-7 <br /> OWNER!OPERXTOR <br /> 90 -""Movma vyv 'rB <br /> FxmNAmE <br /> SrIEM)REW Man <br /> ® 0. mFt ,_� div® cA,r+ta 452as <br /> pf ftm s" ) Nye,. <br /> Name <br /> Clio tJlh - STATE zip <br /> PHOIE(?A� `��7- can � �1 1'3-®S' 1-f <br /> # LAND use r # <br /> PHomE#2 EXT. BOG DMTR= 3 LOCA cow <br /> t ) <br /> CONnUCrOR/SERVICE STO <br /> REQuEsToR Aoo <br /> BummasNAME PHONE# ar <br /> 367 a� <br /> HoworMmmADMW3S <br /> 2# <br /> L3-7a wvA& -t-E #4 (26q) 367—5424- <br /> Cm STATE oA ZP <br /> BUJING A02MMURGE : I,the undersigned property or business owner, operator or authorfired agent of same, <br /> acknowledge that all site and/or project specific ENvMoNWNrAL HEALTH DEPAPTmENT hourly charges associated wiffi this project <br /> or activity will be billed to me or my business as iden6fied on this form- <br /> I also certify that I have prepared,this spplicadon and That the work to <br /> COUNTY Ordkwnce Codes,Stca� 1 d F® <br /> LIC S SIGNA DA E= <br /> / I Z C <br /> IfAPPz a4w is not theBlzd.INGPaRTY proof of aWAmtoden to Title <br /> A O TION TO <br /> above site address, hereby audwrize the releaw of any and aR resulls, geolochnical daft mdkr envircumaddIsite assaska,= <br /> infoMsfion to ftSAN r as Som as it is waileble aad at the sam lim At is <br /> p.?—Med to me or myffi e_ <br /> P- s._, SSP- cif , 0 RECEJVED <br /> JAN 2 6 20 <br /> SARI 40A <br /> AccmwBr. �J C_c V -c �-- 8: Ur 7- <br /> Assmm To.- <br /> ( f �' PIE- <br /> Daft �.3U <br /> Fee Ankount: . �s ev t 6►`— 1 <br /> Paymmt Type sr. <br /> EHD -02.5 SR FOW PoMen Rod) <br /> REVISED 11117 <br />