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i FEB-23-2005 12 :02 PM COLLEEN 344 2644 P. 03 <br /> 02/22/2005 15:3d 209d'�33 FI-TM FLOOR PAGE 02 <br /> SAN JOAQUDM COL 4TV ENVIRONMXNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> rypeolOwlnauarProperty FACLITY100 ii'R/V�l R�Jl6TN <br /> F� S�Y�Li <br /> OYm9RJoPaPwYWt <br /> Yl U crncMM13 <br /> FAdurrNAMe� CL <br /> SITE ADDMa1a <br /> r,2(1 mun—Ill <br /> an <br /> IFiI, MGnft�a �'S33c� <br /> MAIROr MMNOAbpaaeaftEI <br /> If Dlrtar.rte lran+fAe AdtlrwM) <br /> OITY ST. ' <br /> LP <br /> Pxercyl aDN 'rALma use MPLIPATa:a P <br /> PWON1 Y1 u... <br /> aCa O!erakT LowTpn OoW <br /> (� QCONTRACTOR/SERVICE REQUESTOR <br /> IW <br /> NQCU�ifrOR 1 U CrKORNB.LLMLLd4QN7C0❑ <br /> gLQL <br /> 13aaIN9e9 NAR79vC � pH 5 <br /> 11 <br /> Z <br /> Mn a r ILII n ' �MI 4 V <br /> CITY 9TA75 ZIP <br /> C '7 <br /> AMS WTgQ ACKNOWIEDGEMM: t, the undo%signed property or baeieera owvar,operator or authorized n=eat of sane. <br /> acknowledge (hat all site aadlor prgiem specific ENVIWNasFsrrAL H& TH DEPAantENT hourly chargoe uawciatod with This pro)Ret <br /> oT activity will he bflled b me or my haeiuew m identified Im this form_ <br /> I also ontyy that I have prepared this applfratlon end that the work to be performed will be done in accordance whh all SAN lowQVn <br /> COUNTY Ordiaonce Ceder,Stdrrdavdr,STAn daIDWERAL IRM, <br /> APPLICANT"991a — --- -� DAM -2 -. -OS- <br /> NA . <br /> P�aorraTr/Bu..RR(IWVra ORMTOa/�tfANAaiaO Orl¢A Ati raoa�tta AesnT❑ <br /> (fAPP is iter the,JULLNU PARrr pradj yarWeliLdyoa to a3Qa b rcgwbM Mir <br /> ALTHO1La.ATtON To WILL ep_r')NFpRM&UM!When Applleabte,1,the owner Of operator of the property located at the <br /> above mite addraw, hemby authorize the release of eny and all results, gcoteclanicsl data and/or environmentaustle assessment <br /> IaLarmatlon to the SAN JOAQUIN COUNTY EMtInOMAEUTAL HEALTH DEPAkT11aNT as Bonn as It Is aveilebie and at the same time it is <br /> prevAod to me or my mpfcammma. <br /> TYPE OF SERVICE REOulismcr <br /> COMMEPTE: <br /> CI <br /> A=&PTMO pr EMPLOYE O: AaTa: 6 <br /> AsaaneoIQ: _ M EMPu molls Dant <br /> late 9anAa r_n PM already mmptaled): Moomcoc ' P!@ <br /> Pee Amolnk r J!'� Amaattaaitl 1.f t'1'Ff- Payment b e'T- a D <br /> S 7��:paygMttt Type ✓ / InMObsl p Chmk N ga.to Raedvad Oyl <br /> � XA . .�EMD 41-Cl-OZE Ct 4VwAaR POMtpp py;( �,D <br /> newseltvnraeea pE``((C�t��E``1'"vED <br /> R \ <br /> �EB � 4 2005 <br /> SPt'ENV P�lME ZM <br /> N�TNDEPPR <br />