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May. 28. 2008 1 ;23PM ,ESTH EXPRESS STOCKTON No. 8862 P. 3 <br /> SAN JOAQU�IN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type at Boaltim or Nopany � . FgCILV 10 a SERVICE REGUMTM <br /> 00 <br /> OWNER)OP A�RA"T�OR� ^� r.NEOK If R16tma ADDa6tt <br /> FAbtny NAME <br /> C�i�� <br /> SNE AOORE96 S ,r�, ,,,r—lr,.� � a��"^•' 3 S- <br /> 4/ ,.�)mrl Num �_ Smr a <br /> HOME or MAILINO AODIt pI biff"Atlrom slur Addreasl <br /> CITY ---------------- <br /> STATS nv <br /> pity s u. APNa LAND USE APPUOATx1Na <br /> PIWNt AI Fn. BO� WpATONC DC <br /> CONTRACTOR f SERVICE REQUESTOR <br /> ReQUESroR F ECR If 1111&yp AoQ 11111 <br /> BuatNees NAMe °e`' <br /> PxaoE R <br /> PAX I AXXLGSM � <br /> HONG oe MAI ADOReAR <br /> city yr y .STATS LP 5ciL4 <br /> 17,TSS,1p-�C <br /> BILLIN(1`ACANOwI,EnfLFRWI 1, The undersigned property cr bostnem owner,ope ntor or anthorWil Agent of same, <br /> acknowlvdile rhnr all site snd/or project apvcifia GNVIRONMr:Rrnl.KBALTH DIWARTMENI'heutly chnrgea sssoc(ated with this project I <br /> or aClivily will be billed to me or my badness At Identified Oil Chit form, <br /> also ccniy that I IIavir prepared this nppl Icntlon and he work to bo perrarmed will be done In nootrrdanoo with all SAN JOAQUIN <br /> C:DUNI'•;r!rrlinmrer C•arfr r,lTnndmTtr,STA". F IIR 1.1 <br /> API"LIC:ANI"swailATURE: DAI-F,;�:' "7'�.'/ <br /> hRlil4a'w 11toom 0vNRIt❑ OFFmAjoll VIANACIM UTnen AWjIOnl%en Acwrr� -rwo- �.(iHN _ <br /> IJ:Irrv.N'+Nr'i, loot the/ip uNnP JudofofmdhnNutufon to sJgrid requited 74+sdo, <br /> AIITI]DRIIIATION TO RELEASE INFQRMA ONT Whcn applicable,I,the owner or aperator OF die,property located et the <br /> above the nddnnt, lerahk authnrixe Ih0 release of tiny mrd all rotuilt, geolodlnicnl data and/or cnvhwnmanlslgtro assessment <br /> Infolmatian to the SAN JfIAI)WIN CgUN'I'v RN'VIRUNRIUWAI.HEAI.1I.1 DEPARTMENTas soon to h is availobin�nd,atthA"I to IT Is <br /> provided IC Ine m my mprt'sanlnrivol. AAY'tV�t1 <br /> TYP!OF SERVIOR RItOnEnrtio; <br /> caxatP t; -� --- MAY 2 S <br /> SAN JOAOUTN COU <br /> fM <br /> ENVIFtONMEHEAL-TH DEPARTIM <br /> AOCEPrao I{Y RIAPLOYagi: 76 q1 I DALE: Z <br /> AEsgNep TU:'Y LMPLOTFEN: CATs <br /> Data Semite Completed 111 already eompteledll -... StRviai COOL P)E: Zj40d <br /> Fee Amount R_9 . 0 0 1 payment Dau 0 <br /> Paymanl Type W Involoa a Check M toqS1 Rocaivad By: z,G <br /> 61104aan.ote SR FORM(Guidon Rod) <br /> RENADd'+171rIZOOa <br />