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RECE VSD <br />Arx 2 19 2010 <br />ENVIRONWNT HWH S.0.NJOAQIJIN COUNTY Y NVIRONMENTAL I'IEALTH DEPAit-rMF-N'I <br />PERMIT/SERVICES SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST "< <br />400,5,5'003 / � <br />OWNER I OPERATOR <br />CNECK'rf BauNc AnoREs;_❑ <br />FACIL-TI NAME <br />I <br />0 <br />SITE ADDRESS S <br />i n4 Street Number Direction <br />u� <br />> <br />• Q <br />t q I' =•"e 1 <br />HOME Or MAILING ADDRESS (If Different from Site Address) , <br />Stre t Nember <br />street Name <br />Lilly <br />STATE Zip <br />1 <br />I <br />Pn1•N[ ill En. <br />APN a <br />LAND USE AMNM TN)N R <br />(� 1 /�147 <br />O{a2- 4717--021 <br />P i.Nr d2 E+T- <br />80S OISTRICI / <br />40c Cooe <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR1 <br />CHECK If BILLIN4 ADORESS i <br />BUSINESS NAME • 1 PHONE#Pat <br />I HnmF or MA LINGPD E55 FAY I <br />_ i / ( I -< rl— <br />~10 <br />CIN _ i+/STATE �r 71P <br />11,11 <br />iiti LING_A0%,NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same <br />,..N:InJai�t diat all site and/or project specific E; NIRONMENTAL HEALTH DEPARTMENT hourly charges associatea',0h :hi; pr)er, <br />or Iris ^ will be billed to me or my business es identifiedon this forth. <br />thin I have prepared this application and that the work to be performed will be done in <br />Cbdez. Standards, STATE and FEDE" laws. <br />DATE:_(.v.------ <br />- - .., .,.r.�ni)K�F.Ru �L3PE'AAlORI}iAN,LGBR 4.i OryeRA:;rNoRr2t;oAt.>sti1 � ikt/, .Dr�� M� e�r.�_ <br />f .IPPLICJN. Ir 1201 the fufvr,Paar,'. proojoJourhdri atron rosfgn is required <br />i lit) RIZ ATION TO RELEASE INFORMATION: When applicable, I, the owner or operator or the lit upei n !U.mcu m ti:: <br />.' Aitr address. hereby authorize the release of any and all results, geotechnical data andlor enn ir_n: :tial r:t. ;,5:4.17:;,,: <br />PAYMEt 1 to rhe S LV 10AOUIN COUNTY HNv1RON,MFNTAI- HEALTH DEPARTMENT as soon a5 it i5 avaii*l- and ?r the .;rave t+Pe <br />RECEIVED". ,,+,_,+ ,,,e m reorecentati" <br />sa..,ILRUSTE�. AGd*t O�+ Gv�C(L <br />APR 2 2010 <br />EN"AGLAIMENTA r IpVka� &h 2 f n 01 1iit� <br />� r r� <br />SAI <br />HEALTH DEPARTMI IQI(4 <br />-p�Ln'C�te� Irl <br />�aSif.NeC:tO- 5 <br />-.: ,:rq.; <br />Fee Amount: a <br />Payment Type_ <br />:,.r: i i t12D03 <br />9'T:aapd <br />VA <br />B �►>7fwflt <br />6e 141s, <br />8£TOb96602T:c1 ObTTL9S9T6 0bTTL9S9T6:WO,td 92:80 OT02-82-NdU <br />