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SAN JOAQUiN "buNTY ENVIRONMENTAL HEALTH DBrKRTMENT <br /> SERVICE REQUEST <br /> Type of Btnkega a propertyFACg ITV IDIl SERVICE REQUEST/ <br /> i �"7gZ SKoo <br /> r QppIATOR cNeut+r�❑ <br /> n AA <br /> FACUTY NAM <br /> 41 <br /> -811111132L <br /> 111111ess ?�tar[K l +9E1e 5tecl�kft 9s�p7 <br /> ML Zia cad� <br /> HOmE or RAILING ADORE SS Ix axhrwtt hnm SIW Addrar) <br /> CITY .STATE TD <br /> P )W di � AMS LMm UK A <br /> CATION a <br /> (a� ) If. N <br /> P ow 82 9� O4�� <br /> LOCATIGI COO! <br /> t CONTRACTOR I SERVICE REQUESTOR <br /> REMESTOR rreoo r x <br /> P"W/ c•�. <br /> BUSOW 3 NAME [' DL <br /> Home or MA"so-Aomns <br /> f'S _ <br /> t J <br /> Cm <br /> l gT Te ZIP <br /> BILLiy(; aC K::OWLEDG E7NEt�fT: 1, the undersigned property or basiRerr owner. operator of aethoriaed Wil of acme, <br /> a knowlcdgc that all .ile andfor project specific EWROh"MEKrAL HEALTH MPARTMENT hourly charScs associated with this project <br /> m activity will be billed to me or my buslnns a5 identified an this form. <br /> situ certify that I have prepeaed this application and dear the work to be performed will be done in accordatxe with all SAN JGAtrttN <br /> COUHty on-Bnmore Codes,Ssan&m-ds.STA amd)l-T RAL laws. / <br /> AMICANT'S SICK ATURE: 1 oATR:./ <br /> I'ROFcan'1wststwfyw%vxE3 Tall' IR0 OMERAITt muPAGW1WrE <br /> JJ AFPLK.:r.+T is nar MIT tl Petal aatlaizerloR w ska,it reWired tlrtr <br /> At, gl ATION TO RFLEASE INFORMATION: When applicable, 1,the owner ur operator of the property located et the <br /> above site addren• herby a dhotim the wlesme of any And all rftulm geotechnical data ardor envimamentab'site assesune t <br /> infonrMfon to the SAN RMQUIN OW TTY EN IVIRONMEKTAL HCALnt DEPARTMt? r m soar as it is available and at the same time tis <br /> provided to me or my repeesentwive. <br /> TYPE OF SWAMRMAVED: TLS i fZf. —1124" <br /> Ik>�xts: PAYMENT <br /> RECEIVED <br /> NOV 1 12011 <br /> SAN JOAQUN COUNTY <br /> 0 <br /> ACOEmto BY: <br /> ASWWD TO: , EIPLOYeE <br /> Date service Com Iraaotrptw�dpc sietlst�d7oe: PIR <br /> Fee Amount f7 Anrotrrt Pald 37jG OWN <br /> payment TypeU Chea 4 ldanlYad D . <br /> EHO 4"2 t 10 2,.7 3' SR FORM motlrt Rod) <br /> REvuEO t to 7MM <br />