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FEB-12-1996 07:30 P.04 <br /> 01/15/2000 TUB 14150 PAH 2O94c:Ja31 BJC BRD 0002/001 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HizALTH DEPARTWNT <br /> SERVICE REQUEST <br /> Type*(BusinessorPre" FACILJTYID SERVICE REQUEST 0 <br /> S er v ix S-S-u--k-+o n <br /> I OpttltATOR <br /> �(,l. �( � CrrtcxM&ulxo ADoalaa❑ <br /> Faoam WE C�' e r) <br /> BnADMUN 3t}pJ Y►lpG�� llLur (�c Trey q�37b <br /> flmy <br /> Hoge ter lAantaa Aa0RE9B 01 airNnnt from sir.wodnaq <br /> Nang <br /> OITT STATE zip <br /> PNDaee1 aa• Arm LAND Use AFry,ICAUQN0 <br /> t7o�j1 per'`//-/C2zp� <br /> p I Y 0 SU I !u. 1108 WTNGT LaGTWN CADS <br /> ' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> IREIWA teen hIKVICttAL� GN Mt1AWAUAR M <br /> ff <br /> BuaatEse q l p Ca l�tc n� ROM V4 —y04a •, <br /> NOaEaaWWto AD 6rA 1 S'}'- I Ya3 $%2-P3SZ— <br /> GTT n.�-p�1 STATE eA 21NG,Il.S/_ <br /> §,(Id3NG ACKNOWLVDI¢EMENT: I, the undersigned property or busiaest owner, operator or authorized agent of sAmc, <br /> acknowledge that all site and/or pmjM specific ENVIRONMENTAL HZALTH DEPARTMENT hourly charges associated with this project <br /> or activity,will be billed to me or any business as identified an this fraTa. <br /> 1 also certify that I have pmpaod this application and that the work to be performed will be done in accordance with 0 SAN JOAQW14 <br /> COt1NTY Ordinance Coda,Standar&.STA ad FCI MAL laws. <br /> APPLICANT'S SIGNATURE, DATES- /- 1Ip.d._ ,, 6 <br /> PaOpaTv/BurANrae Owr.an L7 OpztuTDrtl MANAcsa I7 Onraa AunroarrAm AcaNt'Le" !/�/lncw�t� <br /> UAPPL .AAT Jt nal the Q/LLIAC.PAAtr.Proof of Aklha/IZgtlen ra sign Is ra0a1re4 Trrrr <br /> AUTHORIZATION TO R%LEASE INEORMA33ON:When appllemblo,1,the owner or operator of the properly IQatod at the <br /> above site address, botchy authorize the release of any and all results, geotechnical data and/or onvirenmentaVsite assessment <br /> information le the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALrii DEPARTMENT as soon as II Is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SR rMReuuF9=. <br /> casaEArc <br /> AecaPrau by: EwLOTCB 1; DATE: <br /> ASNOWD To: Ear p10T[!1: DATE <br /> DateBervinCpnplabd (galreadycompletad): 110W.9CODE: PIE: <br /> fee Amount Amourd Pakl Payment Data <br /> payment Type Invoke N Chxk M Raoelved By: <br /> END 4&W-02a SR FORM Malden Rod) <br /> REVISED 11/178009 <br /> .rams <br /> toot Xtl3 6C:OZ LOOZ/ST/SO <br />