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Mdv 14 2005 2: 49PM RR IMC/TRITON 8314758249 p. 2 <br /> 11%]4/2f•':�S 13: 209'Gbs3 EHD <br /> PAGE 02 <br /> TOA j 74COVNTYENVIRONMENTAL IIEA.LTI-IDEPARrMENT <br /> SERVICE REQUEST <br /> Type of i.�',i ss or of FACILITYIO# SERVICE REQUESTa <br /> A5 5464CC)I,-\ 3r� F 3� i Lc ';�, -j <br /> rtnrti;, \�^ o <br /> V l./`'"'e,0 CNECKI1AILLIWAooaE9s0 <br /> PACILM NAM£ <br /> HGwc ar h;;,, ;ADci:r as Oren:tfo:n 91119 Addtaas) <br /> C STATE ZIP <br /> APH9 Lann USE nr-ucarpNR <br /> l 1 <br /> BOS DISTPJCT LooArON Cooc <br /> I <br /> c. _vTRACTOR/SERVICE REQUESMR <br /> R_ <br /> l'" YghK BOAn� CNECKN&LLIAGAODR6Sa® ' <br /> -..— —...__ .. z, <br /> FAA <br /> 5117 UC/ AJL:— <br /> C: ^ <br /> 5TATc C4" ZIP 7 SCI&, <br /> p` �f ', the undersigned property or u: ,:zss ,-r, op ;- :ur or authorized agent of same, <br /> a :•.i + <br /> If pin .,reelflc ENVIRONMENTAL HE4LTI1 DEPARTT-'\i hourly charges associated with this project <br /> oror rn iness as identified on this form <br /> I z +, X h.:.: - ed tl. ;Iication and that the work to be par.ormed will be Jmw in Accordance with all SAN IOAOVrN <br /> C` r,- � � . ' Idu: t:and FF,DFdtAL laws. <br /> DArr; 1(L/4/dS <br /> ex/MANAGER ❑ OTHx. ' N' ,..,r +++ <br /> t c:.: ( 7_ N icy/ – q�G•Pr!'��_ <br /> u. ;G PARTY.prao,/ofauthorka r r r(fle <br /> At" - '•s .EA; . _OAK TION: Witen applicable, 1,the 0waer or aperatar of the property located At?he <br /> Itho rrlease of any and all resuh5 cotcc ni al d.,la :-nJ/or envifottmental/si assessment <br /> r^ <br /> r. + : �an <br /> a time it Is <br /> .:+viRONMENTAL HEALTH DEPA ft;7 <br /> — RECEIVED <br /> 4 2005 <br /> U 1 1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> A. <br /> W.ry EMPLC i 0 r DATE: _ <br /> EMPI.�rn.:.a: DArz: <br /> q� <br /> PIE: <br /> 'mount Paid rD1� -7 --to <br /> �l <br /> Received By: Z�� <br /> F' - SR FORM(colaen Rod) <br />