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Nov 09 11 04:34p Dutch Nuts Inc. 2095997680 p.1 <br /> S,A,N joA,( IM COUN'£Y ENviRflNMENTAL HEALTH DEPARTNMNT <br /> SERVICE REQUEST <br /> Type of Business or Property FAGLITY IDX S' E liEOi>EST# <br /> 520D1a 3y3� <br /> OWNER OPP12ATt'rit 1*vJE Jitr l DEP—E.n1 0%t.) F�.-DE�EN a'�`r`�•�-":,� ,•`•t® <br /> FAnrrY ELD£CZ EN PFzOPE(2�� _ <br /> j r 142'F7 E. t4tGttwA`{ l�c� 140N RS3lsr(o <br /> HOW r roc M E (N Dithretd(rem Sae address) 1 ea O C) tt v T C N 5 f2 � . <br /> 01" tZtPa>`t aZip `�. cA _ (ah <br /> thtotatt err. APN3ef piJCamMi <br /> PHM d2 ton- 8 om-oxy tMar <br /> CONTRACTOR I SERVICE REQUE <br /> REQUESTOR DRtLE W A.X-Irk CWMKu A&hW ❑ <br /> eoawsssHAM yhQ6 OAK CSEDEN�/{Re� ENi hl a eM. <br /> FAxY <br /> FtwE orutNcwc � tn7- oo Y-- ST. <br /> Cttr !ro t STATE C A I Zip q S z 40 <br /> BALING ACKX0y LBDG'BM2M I, the uadetsigDed Property or busleesa owner, operator or auihorimd agart of P^�, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALnt DEPARTMENT hO WIYcbsrg�s associated with this project or <br /> activity will be billed to nae or-my badwaa as id=Wwd on this to= <br /> I also certify that i have prepared this apphicatinn and flat the wank to be performed will be done in aucc with all SAN IOAQLW <br /> COLWry Ordi»Qacr Codes,Stm¢dwds,STATE and <br /> laws. /�,////� - <br /> APPUCANrgSIGNATURBt 3iYfU [l'r P� 1 lY1',C.a-� MIT <br /> Pnorviry/BuerKwm owK=[3 OHMATOR I MANAGER Q OTMm AUTMK aan Acrnr 13 <br /> if APPLrcarr it not the B&WgG PAa7r.proof of audwrizafion to sign is refidmit rule <br /> Whey appbcshlo,I the ossa err operatc'r of the Property located at the <br /> above site address, hereby aWhoriae the release of any.and ali reseal, gest-•-buu-1 dela and,°c'p'�enviromueataUaiAe nesessmmt <br /> iffior=rion to the SAN jOAQU N©RUNTY PNVL ON6�JTAL HEALTH DEPARTMENT as soon as it is avhilable and at the soave bine it is <br /> provided to ing or try fcprrsa alive. 1 T <br /> TIPEoPSER=ERECuES E: REtltEvJ SOe� Su t'rr'.8tt_'t'C,{ S't"va`f RECEIVED <br /> CcaNExrs: 3 0 2011 <br /> 2- a�bG�ti�,l Fu sNWW,,oNMit�w <br /> DepARTIAEll <br /> Aa,Evt�6Y E,>PLOYEE# <br /> DATE L <br /> AsaM:taAm "._ '7�.dEt-to EMPLOYEE#:' 4o y C ♦1AA7£ <br /> Data Service Completed (Kalraadycem Wk - 9er Cote Z 2 _ PIE 'Z <br /> Fe.Momot' '-� Amount PaW ''(r',SG, p^ Payrrtant Date 1 )— �, , <br /> parnraaf Typo 4rralca s ctw,** Repivod 8ie .L .4_ <br /> Ertl]48m-025 SR FORM(Golden Rod) <br /> REWSED 1IM/20W <br />