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EB/02/2007/FRI 10: 33 AM FOOD FOR LESS WH, FAX No. 12098580108 P. 002 <br /> FEB 01 2002 9: 44AM LASERJET 3200 P- 2 <br /> I SAN JO QUINCOUNTYENVIRONMCNTALHEALTIiDLPAR'PMEN'P <br /> SERVICE REQUEST <br /> Type of Buelnoss o PrProperty FACILITY ID Y SERVICE REQUE5(4 <br /> ST M <br /> ' IT <br /> a SrA-t <br /> OWNER OPERATOR <br /> �OleI CMECMif eILLWO ADORES <br /> FACI{ITY NAME <br /> k->M�CHU � ,a-.J �i C�.zcE l� %'rel �. <br /> :IrE,A Gaol <br /> {/4 <br /> IN ht, -il Ilan flree Iles I 11I <br /> HOME or MAILING ADORES$ (1I Differi from Silo Address) cen. <br /> CITY 6vee umbo .el <br /> I STATE zip <br /> PdONE$1 1. APNE LAND USE APPLICATIONM <br /> I I I 0 t/-7- esu - <br /> PHONE IZ f .. BOY DISTRICT LOCATION Come <br /> 1 ) <br /> l` <br /> it� <br /> CONTRACTOR /SERVICE REQUESTO <br /> REOVESTOR ' <br /> CHECa It BILLING ADOPESS <br /> GU ESS N/ft� ^ PHONEN En. <br /> How arMuuna DDRE S FAX <br /> 11' 1 65P <br /> CIT STA ZIP gp <br /> Ull-LINC 6CISNOWLERIP8114FT:'1, the undereiimcd properly Or business owner, operator or authorized neeul orpaille, <br /> arknuWlcdgc 1)131 all site and/or prof CI SpeClrie rNVIIIONMEN'TAI I'IEALTI'1 DEPARTMHN r huwly Charges associated will'Ibis prujvct Dr <br /> zttivny will be billed to ma or illy bI sines as idcnti0ed on;his form. <br /> I also Certify that I have prepared thi appli n and Ihat diew - fo cJ will be dons in accordance will,all SnN.Jnnquln <br /> \� <br /> COUNTY Orrlinullrr Codes,SrunAarr ,S Y { EDURA la <br /> x <br /> APPLICANT'S SICNATUR6: DATE, +Z1r7 <br /> l ` Irltul'EI{TY/DIINIHY'LN OwHY.N�. Ofr.x%TOH/MANACeR� OTIIHm AUTHUROAD ACaNT❑ <br /> l/ArPut'ANT i:Y HPI Ill i'll I Pe117r prou/o/aNiGariiNlon 10 Wgn Is requirea T'n6 <br /> AUTligni7wrioN TO UASK INR RM T N: Wkwopplicable, 1, file owner or 0parntar of the property located at the <br /> ]EOvc Site Addresr, hereby mHhori c Ilic release or any oqd all results, Scoleehnieal dalo and/or environmen;aVsile assessmcln <br /> it*mintion to the SAN JOAQUIN COINrY BNVIIWNMI:N'IAL11U4'l1t DEPARTMENT ae 30011 as it is available ondt3l the sane firm it is <br /> provided to me or my representative. tgYM <br /> TYPE OF SERVICE REQUESTED: LL I VFX <br /> COMMENTS: <br /> EN oAQW <br /> HFACTH 0 PqR 7Y <br /> FVT <br /> Appmoveo err r L t t t' r l EMPLOYEE IY[ ! <br /> C=� z_ 'I .. DATE: 2 2 0'7 � <br /> EMPLOYER.: X317 DATE; <br /> 2- 2 07 <br /> Date Serviee CemplNed Ill airoadyc mptstod): SERNaE Caoeo <br /> Foe Amount: SSS c-ti Amount PaidZ3 `� <br /> S . -O-6 Pa9mont Date a, a p1 <br /> Payment Type1� Invo ea Y Check tY <br /> 'L 0 Received 13. <br /> EHD 4"I1 0t5 <br /> I? V.SED G 5-02 SERVICE FE n <br /> 1,J o� <br />