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03/30/2004 10:36 4085321gr-1 JD PROPERTIES PAGE 02 <br />03/26/2004 14:08 209468.3 FIFTH FLOOR PAGE 02 <br />c+ar uui cuur UO: 1J �3 FIFTH FLOOR FACE _t; <br />SAN JOAgUIN t• OUN i Y-ENYMONM$NTAL MALT11I DUARTMENC <br />SERVICE REQUEST <br />Tie of useless or property FACIUT'Y ICJ # SirRvl Cr, R�CiUEST <br />• =1.7 <br />FaCII.RYIVAMIE GrfJrS 5 s A_TIor�j <br />8111 ADDRESS <br />`TI -7 vv. 0-41s-r�-r <br />St tNu r Dlreetlen sereelNarnc <br />FIMor MAILJW ADDREss (it Clfhwent from Sin Address) <br />3�'1% I r.J't !"� d N i' �.., StmltNum <br />OW <br />!SyktJ 0 0 s 117 <br />R+H&'Ck if �tLNIG rj�g5 <br />JCllA4 .. <br />G1r41r_Ie___r6fJ _Tq,.5�-a4.d <br />sra,r ZIP , 8 <br />f8 > 69 " Q UO LIZ - <br />808 <br />% i# -d `' LAND USE appLtcar+a►r # <br />PRDt16tJ EV, DIBTitrcT Locanam Cons� -- <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />-j Q a D 74` IQ (![ . I rz_/Jr- N/ CNGCK if EULUN 0 ADD.ICZ!; brl <br />llwI =NAME <br />cry 4 </0 s cA- $ � <br />T,I �CKNO�i'T AGE_l+�El� ; T, the undersigned property or business owner, opetrater or authorized, want of tame, <br />acfmowlCdge that all Site and/or project Specific ENvtRONIteNTAL IiEAmi I)EPARTMINT hourly charges amciated wick this pmjtcl e r <br />fiedvity vAll be billed to me o- my business as identified on this foam. <br />Il also certify that I have prepared this application and that the work w be perforated will be do= in accordane e %irb all SA1J Xo,QUIN <br />C OvNTY Ordinance Codes, Sranddr.dS. STA - and FEDERAL laws, <br />A'p`P>I.IGANT IS SIWATU Rr: <br />1?ttOPER BUSINFMOtiMtEp9r+ OPERATOR IM AGER OTHMRAUTRORIZED 4CrVT <br />lfAP Lzt AfvT is nOt tine BIL LFNG .PARTY proof of authorir46#N 00 Sign is required <br />AMMO -I RATION T() E_kSE TAW. OKMA.'TIUN: When applicable, T, the owntj& evaporator of the property locatecl at rhr <br />above site address, hereby autnorize the rcleasc of any sod all rosults, geotenhnioal data and/or aisserstnd tt <br />Wozz don to the $fit SOAQUN COL`vTY ENVRQN1WrWTALHEALTH D9PARTMENT as Soon as it is available rpvmva" iliv ill Li <br />provided to rue or my represertrativc, r- r, r_i V EC- <br />TYR of Souks nclutsreu: <br />4w <br />Col1110tEUS: <br />NT <br />C0014 <br />oA 04N <br />ENVIRONn _NT <br />HEALTH pEPAFRTME <br />Accepmo BY: % <br />3 <br />EMPLOYEE : 7 (' V <br />/ <br />GATE: <br />3/- v <br />� <br />AN0 TO. <br />sa <br />F_MPLOYEM#: <br />DATE: <br />flats Service Completed IN already completed): <br />SERVICECORE: , <br />p E: Q� <br />he Amount: - ��1 `1 S. p <br />Amount Paid <br />IC l `iS. 0 O <br />Payment Date <br />a � p / , � <br />PayM$nt TYM <br />Invoice <br />- Check o� S`3 <br />Rctct:i °d Sy_ II(ILT <br />WiD 402.025 $R Ft7k t (Gddon FzldJ <br />IWI$SD '11111712003 <br />