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:iie/16/1005 09:01 2094603433 EHD PAGE 01 <br /> SAN JOARUXN C007y ENYMONMENTAL HEALTH DFPAIR'J MF.NT <br /> SERVICE REQUEST' <br /> Type 01 tlwlnesa or Property FACIILIITY ID I , gt RVICp a@gUHST p <br /> tSTa 1. <br /> _( 7 <br /> OWN61tl PEMMTOR <br /> I LAC PF CNHCN II RLLIbn ADDW <br /> PAWTY NAME <br /> BITE Awatsa <br /> HOME Of MAILING ADORE55 (Ir DllTcrant from 6110 Aadma,) <br /> DItT <br /> 'ATAra 7.IP <br /> PxpNE 11 'W. APNd LWD Ute AffllOAnoNt <br /> I I tlos tasrawT � LncArloN POoa <br /> REQ0ES7OR CONTRACMPI/SERVICEAE,QUESTOR / <br /> cNeru lryty�aeon0s�[] <br /> Ov5INE"NArea <br /> NOs[a or Linc ADQRE99 !s !t <br /> Q -rrGi�7'�,Kj <br /> •. enY BfArR � av <br /> BILLTNC ACILNOW <br /> L.ED(��V�; I, the underalgRed preporty or euslaas owner, operator or autDOrizrd agent of same, <br /> sokelOWltdge thAT ell site aind7or profoo11 speeM 6NvmvxNMNrAL MALTta DttPARTMENT hourly charges Woclot4 with this proJem <br /> or acdvley will be baled to the ar rnY b1512#15 As Jdentillcd on this flam. <br /> I also 001.11y that 1 have propared this■ppllcatlon and th Mat work to be performod will bt dont In accordance with all SAN Joppun4 <br /> 1111 ,, COUNTY Ordinance Codes,Standardr,STA Et RAA�YI. <br /> X APP W CANT'S SIGNATURE' Dnr¢: L D Y <br /> PRDPTRTYl BDANFe90wNrA13 OraOATo,R/IyanAPIlt <br /> 1[ 01116A AVTlloeatED AO[Nf❑ <br /> If AP/11CAN71sr1olJllfQf,(�,pro0 ejuugmrlmNonlDalynlaregulred , rgrr <br /> AUve fit* ZA7YON ere R&LFASC�NPgPthfATtON; When 8pP1IQble.411110 owner or operator of the property located a Iha <br /> obave rite atldress, here aLldhorize the release of any and all Muhl, 9*01e01141oal dots andlor envlronmenmLslte assessment <br /> infvfmUiOn to the SAN JOAQUtN COUNTY EtMRONM¢NTALHEALTN WARTMENTaE soon W It Is avallablt And at �o�P l�ime <br /> provided to me or my representative. It is <br /> r u1F <br /> TYPE or5ERYICEREnvc-VED: (_( 7- <br /> Conurxral C <br /> SgNJo 1 3 20p8 <br /> H ENVigp //V Co <br /> FALTMO PARTTAt <br /> 'SENT <br /> Accep7E087; EMptDYar0! �'.' 3 Z. bAla: 1 <br /> OC r L"vr r�-r} <br /> S <br /> Aaalr;Nao7a. -�- N:4f i)t.t. CMrwTEE Nf <br /> Dau Servlet CompletedItt aaeyey e,mpbtad; <br /> 1 SERvICs D(AiE: E: <br /> Fee Amount: cAmount Paid t Payment Oate <br /> Payet Typo � Invoice Ip CneC117J I <br /> b Recalved ay: <br /> EHO 11102.065 <br /> REv16ED 1 V1712003 BR s'ORM(Ocloen Rod) <br /> I 110'c 7 ;'r d Hl�l �7 ,,Ii M.I jII 1113 '" = <br />