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SAN JOAQt;IN COMM—TY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busims or Property FACUn iD alk SERVICE REQUEST# <br /> Re t2lm wza&L ��1- aod� 3 rL SIZ(Z)O8- $a3 <br /> OWNSR J OPER&MR 0 <br /> CHECK if 8?.Le��Aet�RC;� <br /> FA:Fjrr NAME �- <br /> _- tr' <br /> SffEAO %ESS <br /> •T75" _J S•JC6:1}�n�,S[�, ..y?'1 ��.I rF4.d, IrNM Abl � <br /> HOME Of MAILIN:i AoDRESS {If Gifferent from Site Address) <br /> li - <br /> Nuge <br /> CITY ALA :3T ZIP <br /> EXT. <br /> A,PN x LANo tJ$*Aare; TION <br /> PHow#`! *. SUSDIaTAICT Lt7cA.novcost* <br /> t f <br /> CONTRACTOR/SERVICE REQI. ESTOR <br /> 2�� (yu/ <br /> Bt71MF.SS NAIVE f+i pf En <br /> ' / p <br /> +i ✓ L.c7tr'"'[ %!r- 1P <br /> Home or iNww ADDRESS FAX 0 <br /> 7-11 Yr <br /> CITY 7 L J sy r f° i STATE19 ZpP <br /> BILLING ACI .NCriWi-,E0(,;sE 41ENT: I,the undersigiwd proptrt} or business awlur, operatar or aathorkted .agent of same, <br /> acknawlefte that Il *iI andior project specific FtaviRLINMf:NTAL. FIL:AL.Ttf DEPART:NBN t hourly charges assmisted with this project <br /> or Wivity will be billed to me or my busine"as identified on this fort. <br /> I also certify that I have papered this appl'i"tion and that the work to be perforntd will be doese in accord-mice with all Shw 1oAQwN <br /> CouN€Y Ordinancet e�.4..�dc7J7�GrfidPS'.ST.4I1 F[D RAL laws, <br /> APPUCA.NT'SSIGNATURE: <br /> P>+LWERTY I MAJNF!W�01AINER - 'OFERATINt d MA%i oGrR ❑ t ,nun t AvrNoaazEo A.FN F❑ <br /> 10PPLICAS'T is nor dtwW .k yn Mxfgr s l1 eruTr <br /> ir <br /> AI:T1 10N TO RELFASE INMILMATION: When applicable,I,file owner or operator of the property k4wed at file <br /> above site address., hereby authorize the release of ally and all results. geotechnical .-lata andJor envirnnmentalrsite asw—�stsmt <br /> infafmation to the Safi JO AQUIN COUNTY EX 1R0Nhtt--:MTAs,HEAL.1.11 D1,?.-%xr tIE'_v'r as soon as it is available and Rf the Same time it is <br /> pr"ed us Ine or Icy repmsentative. <br /> TYPE cwSERKEREQUESTEp; M �. <br /> Com: V <br /> • D <br /> MAR 14 <br /> ?0 y <br /> SAN JOAQUI <br /> NEACTH I—A T?' <br /> pE A <br /> AocepTeo BY: 1 F—up oYEe :;- ^� DATE: 3 11 I Z tvr <br /> Assiawo TQ, /_'` EMPLOYEE IE O DATE ?� 14 <br /> Daft <br /> 2 <br /> Date SOraltae CompC vW (if a irs&*corrrpleted): SEP,vI^.EC00C 04 1 1 pie: <br /> 16 <br /> Fee Amount: A I C, Z 1 Amount Paid �jz. Payment Date 3 1 <br /> PbimentType Y=4 Invoke Chack0 10 17 9'+77 419- Reicelvid IRy: <br /> EHL)f.S-92a3 5 {�, �o I /6 SQ FCthy Rorie <br /> RFVISED <br /> �t�IbZlS3 <br />