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iipr 05 04 03: 49p RIS Consts,.jction 760 X44 1419 p, 3 <br /> APR 05 2001 8: 31Rhf *RSERJET 3200 ' <br /> SAN JpAQUIN COUNTY Xi,NVIRONMENTAL HEALTH DEPARTMENT: <br /> SERVICE REQUEST <br /> SEMAGE,REQUEST I <br /> Type of Business orPropartY <br /> FACIt_lTY101. <br /> Y VA ' �. <br /> OWNER I OPE RATO CHEGtif 9 a s <br /> FACL" -y <br /> ``__ <br /> SItEADDRE5S mea }apt1�() AvIF—' <br /> Nu,.e.� 1 <br /> HOME or 11f oinerarn from Stt Address) <br /> S TE ZIP, <br /> CITY /VC �/ + L�/ Lwr�o UsE APpuC,A1*"g <br /> APN s <br /> PZE KI V <br /> l l BOSotaTR$Cr LOCATKYNCoDE <br /> ell. - <br /> PHONE 02 <br /> CONTRA CT0R ERVYCE 1tEQIJEST4R <br /> . . C/40rJr I! LN AopRE D <br /> EBusiINESS <br /> TOR <br /> / EXT. <br /> Pstar►Ep e <br /> NAMFAX 0 <br /> llllp►Lp4 ADDREs <br /> STATE(J�l*A u ,ZIP r <br /> CITY Csc <br /> ar m ect s2,Uace BNYtRDMMtENTAt.HEAI.TH DEpAjLjmf;NT hourly char�a associated wish this project or <br /> ILLINC A AW U E T: I, the undersigned property or bUK100s owner,operrior or'puttrortzed agent of some, <br /> acknowkdge that all site and( p j <br /> =clivity will bcbilkd to me or my business as identified ern this form. <br /> i also crrtify that i have prepared this application and that d t work to be performed will be done in accoriiance with ail SAN Iont2utN <br /> COUNTY ordinance CpdeS,.Siandard;r,STATE and F RAL 0 <br /> DATE: <br /> APPLICANT'S SIGNATURE: <br /> PRorrurrl8usINRSS0WNSa❑ 'OrEaAToK/WtOACER OTutQAVTHORtzEaAG¢r+T❑ Terra <br /> If ApPUG uvr ix nor lite BfLI iprPof of aerr6orkurlon to sign is regnirerf rt located at tine <br /> RUTH R77,ATION T <br /> I EASF 1NF RMAT :' °appl'�cable,I,the oirner.or operator of tho propc y <br /> =bore site address, hereby authorize the release of any and all results,'geotecEwieal data and/or enviroArricnhl/site assessment <br /> info a sit al d the 1, h IOAQUIN COUNTY ENY1RONMENTAL HEALTH DEpMVMFM as soon as it is available and at the same lime it is <br /> r ; <br /> prpvided to me or mY represuritative. . <br /> TYPE Di SwiCE REOt1ESTED: <br /> COWMENTs: A P R <br /> SAN JOAQtliri ',€ <br /> 14EA1THbEO W AW. ... <br /> EMPtAYE2S' <br /> 11'l. <br /> APFFtO Ea ar. ( ( _t L [ F- �. HATE:' 1 <br /> EMPLOYEE.S: ,.. <br /> ASSJGYtFD rO: n �. L, '} ' i SErtV7cFCtsoE: P 1 E: <br /> Dale Service Completed lit already cornp'etedl: <br /> , .. .. _ <br /> Fee Amount: C �' <br /> Amount Pall Payment <br /> dote 11� iei' <br /> Cheek# Rcctatvad y: <br /> PaYrnenl Type � Invoice R • <br /> SERVICE.REOUEST FORM <br /> Etip 4,&41-075 <br /> REVISED 8.5-02 <br /> �� Z Z`' <br />