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88/18/7805 89:01 2094688493 EHD PAGE 01 <br /> 40 if <br /> SAN JOAQUIN COVNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST, <br /> Type of Business or pro psTQ FACILITY ID{ <br /> S2RVICE REQUEST 11 <br /> OwNtRJ PERATOR . <br /> PAcxm NAME �L CNECrr If I s . <br /> 211,AAaRESs 994 <br /> Y s Ir le <br /> Hold?drK41LWOAf�OW (ltDlfroront+•dmShe AatlAa,) <br /> GTY <br /> STATE <br /> PNOIC.fi 'r-n APM 11 <br /> - LAND Uer AP WHO <br /> l I ' . <br /> PryONi IQ �,. <br /> 1 _ 803 DISTRICT LocAbon Coop <br /> CONTRACTOR/SERVICE-REQUESTOR <br /> RaoWtsTOR <br /> .` — CN6CIf lT¢laalNO ADDa•S a <br /> BUSINESS NAM; <br /> Howe or MARINO ADDREs9OL <br /> CVT' 7TH 7+3 J <br /> 19TA1E ., Zlp <br /> 9FA,ING ACIt74ppY .tTraCaAm; I, the undersigned property <br /> acknowledge that ell silo m �specific ENVIRo tdENr�HI/,LTN DpPor A;tIU NTrhourly cbnrgesOPOrDtOr Or Jauocland witthnthis Pref eet at , <br /> of activltYwlll be bllled to me or my buslmes u ldenti8ed on Ihls rbem. <br /> I also Ocnily that I have prepared this application and o work to be performed will be dont In aecordence with all SAN JoApuRa <br /> COUNTY OMMence Codes,Stand",S'r � pe ;• <br /> X A rPLICAMI 5 SIGNATURE: <br /> / nntn:_ _ <br /> IaDP.cRTY/13Va1Nr890wN6R� QYYR.\Ta,RJ MANAGER OrrurS AVTootume ACENT❑ A �� <br /> JfAP/CHANE iS nnlllle Bll(.INGPAR7Y prp0p!/1(llfj9/1P11(O S/P/I 1S regrlbld Z/rre <br /> A.U'1!'HORIZAa'ION_TO RRI.k!g .rue.,e....'....I,When applicable,f, the owner or operator of the property located aD&b <br /> above site address, hereby oudlorize the release of m and off resuht, ga0lechnioai data end/ur envyvnmenuWske <br /> information to Ice SAN Ja1QU]N COUNTY EN%AkONMnNTAINEALrN OEpARTMENT as soon as It is available and of the same time It is <br /> provided to,me or my tepmanlmWe. <br /> TTPt Of SERVICE REQUESTED: <br /> CetlYeXrA <br /> ACCEPTED By: Emp1.0Ytt/: <br /> DATE; <br /> AS7ICNED iOt IiiNpLoys;Ng <br /> DATE: <br /> Date SYwka Completed fn already eempt•t•d)r SIItVIot COOL <br /> Fee Amount: Amount paid pgymenl Date <br /> PaymentTyp• Involcea CneckA <br /> Received By: <br /> RHO e"..T.0a6 <br /> REVISED 11/118003 SR FCRM(Gnlaen Rod) <br /> =in ' 7, ,. u; vxa 'uAA ccarT YAJ nnna Iola cantcnlionn7/rT / a <br />