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10/25/2004 09:04 9167067891 ENGEO INCORPORATED PAGE 02/0 <br /> ' 10/22/2Htl4 1b:br1 4b4�3 ENVIRONMENTPL I -TH PAGE 02 <br /> SAN JOAQUIN Cb0N'I'YEa�y � <br /> NWOONNI NT*AIL HEALTH DEPARTMENT <br /> SX <br /> Type ofBwinmorProperty FACII-IfYIG! immCEREWESTS <br /> �o qc : , <br /> OwttER/0P��7oH pyE,pt%e,iuHc Oran sa� <br /> Ci eui�14 � LLc <br /> FabalrTRAIE <br /> "M orMAdstoADDRESS (hDn7atomttomShaAddress) ZZ24) Ou44WA k�i0�+ttLJa�P` q�' O <br /> Nanber <br /> STATE 7JP <br /> Cmr G SLL <br /> pttaFlY •. AYR a UM UN AAPLICAT10N a <br /> .� Pgla 1 39C-8d8 1 _ vl P4_d - �` M <br /> PMOSOExt. 808 DIatRICi I DCg'jgX GVDE <br /> 1 .. j <br /> CON[ RAC P,! SERVICE REQUESTO)R. <br /> P:EQVESTOR � 6. h�1 C. ��'S eNEu%�iatD � <br /> Ezr. <br /> sumo Ess NAME �..7-, e. c� p 7 kJ�:s Fir}�Q p <br /> HomEor IllmuNG ADDRESS 3 1 � �^n <br /> FAX <br /> D Alii, - ! (J / <br /> TATE Zr <br /> EILTNG AMOWLEDGEMEN[: I, the updersigned property or business owner, operator or sutbor4tad agent of game, <br /> admowledge that all site and/or Projcm specific$'mnDNMEN7AL 14HALTH DEPARTMENT hourly charges assecinted v,& this project <br /> or so ivity will be billed to me Dr my basiness as identified on this Yearn. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordonoe with all SAN JOAQ11R4 <br /> CjDl r Ordnance Codes,Stardmdr,STATE and FTOSPLAt l VSO 'lZr.r p.rJ-,k <br /> �( APPLICANT'S SiGNATIME: DATE: <br /> `i` PaorenTY/8osmkss OwrrrnL� PrxATane/ ,Acaa On#ae Atmrou>�o Aorarr�7—Prop sere vYL.,..�r <br /> I r rw P ,,(hffjmadm Yd 9 ICC r e4erred <br /> jj"APALX..1Nr iR MDl r7M B! ARTY pIVdfOf t$n <br /> ALrr90Ar��TIO a!t AL�ATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all resuhs, geO"11i0 <br /> 8 <br /> 1 <br /> data and/or rnvitonmentaVsite assessment <br /> information to the SAN TDA(:u>N COuNTY ENVIRONMF]rTAL HMT14 DaARTMEW as soon as it is a "Alskando the same time Itis <br /> provided to me or my representative. <br /> TYPE DFSBwEi RE*uWw: �-SGIL- rSu 'V <br /> OCT 2 5 2004 <br /> SAN JOAgUIN <br /> HEAITH DE ART ENT <br /> y8 <br /> AccEF=El n L t L;E r��4 EMPLOYEE A: 3 24 Met: (D s O <br /> Aa'stcrffo lo: EWLCTEE M I -5S ORre /0 2.S O <br /> IfESS <br /> Date Service COMPIE Mq (saRuudytatmptatedl: 9IRRa ,`z-Z Pf 2, <br /> FeeAmwtR: firJ AmotmkPald Payrrrattps <br /> , bE <br /> Payment Type Imolea 11 Check N RacehMd 9y: <br /> SR FORM(Waan Rtrd) <br /> EHO 48-02-025 <br /> REVISer)1111712000 - <br />