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10/27/2003 15:59 2094671118 AGE STOCKTON PAGE 02/02 <br /> 10/27/2003 15:10 209465.}t3 FIFTH FLOOR u PAGE 02 <br /> bAN JOA"CoUM ENYMONbl NTAL HEALTH DETARTWNP <br /> SERVICE REQUEST <br /> Type of Huslneas or Propertyn <br /> dl a a . u I rb b t" 11M, � » <br /> a r��11 ']x III iM i Mi1�79�, 4 >.. <br /> OWNtcR/OPERATOR +d.. . d„I_ <br /> CNECKN&,�at= � <br /> FAtam NAME <br /> S ADDRESS <br /> NumberI <br /> Homo MAMMA ADDRESS (If DIft ent itaa 8”Address) <br /> STATE <br /> 9j,:;) Luo UseAvruoATM# <br /> SE*2 <br /> PRO �.. <br /> icl -4 <br /> nM W.I <br /> RE4Um11DR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> _ .y�,/� Jp � �•/`•1 U t� <br /> SUSMSS NAMA4 11 `X�• GIECK II CttLw¢ RE9913 <br /> HOW orNlAantOADDReaa <br /> Fuc* <br /> crrr - ( _ ) b <br /> Te zip d( S <br /> 'd' G'LC�T� �68MFN1'� 1 the undetsigted property or business <br /> aebJoavle d+at aq site and/or project speciec.ENy1RoNte mer+ Opera for or authorized a gent or Same, <br /> aetivi will be billed to mo ar m"tt, TR DEPAATI hmly ctarges associated%itJ this project or <br /> #' my business as ideaii;0ed oa thi,form, <br /> 1 also rmtity that 1 have prapatcd this application and that the work to be <br /> CAUNTY Ordinance%d4a & ._NTE g Fgn1�.�L laws. Pied will be dyne:uz accordance nth a1.gva JOAQUry <br /> A"UCAMn S[GNATl7RE- <br /> PaOPHtTY/$US7iVS650W1tl ATE: <br /> aRp 0 RATOR/MANAGER 01 OTttaRAureoatzMn AceMr <br /> rf9PPLJGINTi5 nor McBatrrvcP-4 rpr'aa1 Vfauthnrdzat+aro rs sige iv,equired <br /> b T� 1-1'EAr40 nIATTQ 7:rre <br /> above site address, hereby authorize the re� 1 Whan applicable,I,the owner or operator of the property located at the <br /> information to the SaN JOAQUIN COI �' and all results, geoteclmieal data anYOT environmentSlle'he assessment <br /> Provided to me or m r r EttvtttoNsreNTAL HgALTR DrrAttn teNT as soon as it is avallable and at the;am:bare it is <br /> Y CP esautadve- <br /> Tral oFsERVICEREaOe9TED: PAYS <br /> gosrlans: <br /> OCT 2 7 2003 <br /> PAN OAQUIN COUNTY <br /> UBLICO HEALTH S RVIC S <br /> FNVIRONMENTAL HEALTH DIVISION <br /> - <br /> 4iN 14 a171a L � <br /> •A '"T" "/'1 {A'aIQJJa <br /> tiyy,� nt I f•� <br /> fi �•'S .� ^J . ��p <br /> ' <br /> :�0I <br /> EHD 46-01.025 ^' _. e <br /> RII ISCsp 6.1 <br /> SERVIOE RE-IMST FORM <br />