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• SERWE RgauEsT <br /> Type of Rosiness or Property <br /> FACUrY ID# h St:iMCt:REQUEST x <br /> 60.UNG PARTY r— <br /> Qwmul J OPERATOR <br /> A I <br /> FACMM NAaE <br /> SiTEA00RFss K &i'1"k) TIM subs <br /> i <br /> mailing Address (if different from Site Address) r <br /> 5fATE zP Kyr. <br /> gr. APN# L-m LISE AiPP7=-tM"# i <br /> PstoNe#t <br /> WcATroN Com' <br /> PNaNs� e� BOS lltsTnts:C . _ �: , . <br /> CONTRACTOR!SERVICE ItEQUESTOR <br /> ftlJ G PARTY 0 <br /> RsuUEMR <br /> PMNE# <br /> BUSc(W NAME_ —, Zo` -,,S <br /> FAX <br /> MAjL pAotl = Lo°) 3L_ <br /> STATE 2i 2^q L <br /> BILLING ACKNOWLEDGE L ft uod&*nW property or busineso owner,operaoor or auttrart ed agdrrt of seam.edmowWp drat all sibs MUOr project sPetitic <br /> Puauc HpliN SEMA=qMFEMAWK EMTH DNrsrerr twudy dwges assoaatad wdh alis p*Ad a aGfA*wet be tied to ms or my tsasiness as idend lW art fhfs b= s <br /> ,.,&a cu*titer I have prepared the.application and alar the worst to be pedonned wil be done in acaoretance VM aft SaN.bA<xrrN COWO ordnance Cadet ShvxWisv SUTH and <br /> 0 <br /> ���-- DAM z v 3 <br /> APPUCaxr SW"nNtE <br /> PR0pgkrrj&ZWSS0W R f7 OPEMMt I MM&ACM ❑ pT}ttRArlTNaR�Ata1sT Q VHSrt APPLxmris ndY+►tfy�d�ffDa�tJorr C*S(P b rnani�d <br /> �1U _OR1ZA NT RF'1 Wr=1N1` Rb1ATI0N:When aoWnble.L no mgr ar aperamr of the property breed attire above sit addres&heretrf auMcras ON release of <br /> as <br /> ate cent iaformatson fo the Sit.10A0UMt CaAm PUFF HPI T"SMCES EaAwweax HM'H ONt6M as soon <br /> any and all r8sWl9.geotechniref data andlararvsa �tep»3s�tiwr- <br /> as ft is Valbole and at the same tlme a is provided <br /> T(PEOFSEFtAM RREWSTO: 1 gP� <br /> Corwtatrs: <br /> PAYMENT <br /> RECEIVED <br /> FEB 6 2003 F E B 0 6 2003 <br /> SAN JOAQUIN OOUNTY ENVIRUINIVIIEO HEALTH <br /> PUBLIC HEALTH SERVICES ENWRONMENTAL HEALTH DIVISION PER 1lT/' R1Pirl S <br /> auPr�csaxs s Coanuc R`S Stcr AWRE <br /> APraDAM <br /> 0vE0 E�tarw#: O o o: "v <br /> eg* DATM <br /> ASMM M: <br /> —aft ' P t E � G <br /> Def + <br /> he Amount: Amount Paid PaymarK lG 3 <br /> PaymecttType Invaict±# CheckA <br /> ZO 39Vd HOO-ld H1dIJ 6EVE89060Z Ztl:80 £00Z/ZZ/T0 <br />