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02/05/2003 08:11 9163712450 BZ MANTTANENCE PAGE 02/13 <br /> SANJOAQ0 COUNTY EmRoNmENTAL RZEAL TARVARTMNT <br /> SERVICE REQUEST <br /> Nx of Busims or ropetty FACLITY 9) SERVICE REQUEST I <br /> OWNER I OPERATOR, 1:3 <br /> FAC]utyNAME <br /> SnAximm <br /> HOME or MAIL=AomEss (if 0llt from$ft Addmu) <br /> Nmbw <br /> cm BvATL zip <br /> P"aft#1grr„ # LAND USE APPLICATION 0 <br /> L <br /> Z'T �Ml�-) <br /> PHONE 92 SOS 015TWT LOCAWN COM <br /> CONTRACTOR SERVICE REQUESTOR <br /> Ef)I� <br /> Busks NAME En. <br /> 7V 1 <br /> Home or Mmum ADDRESS F # <br /> IECY " oo )ILI 7/ <br /> CITY ILL&f STAU zip <br /> B1LLfNq-_AC XN0_WLEVDKNM: 1, the undersigned property or business owner,operator or quthorJ7,ed agent of same, <br /> acknowledge that all site and/or project specific ENVIPONNE.NTAL HEALTH DEPARrAENT hourly charges associated with this prqject <br /> or activity will be billed to me or my businem as identified on this form. <br /> I also catify that I have pirepared ft application and that the work to beper(bruted will be done in accordance with all SAN JOAQM <br /> COt1N17Y Ordiwnct Co&s,slan&'�*—�. rE and FErc-RAL laws. <br /> APFL1C,&NrS SIGNATURE! DATE' <br /> PROPF ATV I 11MMM ClwNZR113I MANAGER0TjWjtAVM0At7.t1)A=NT13 <br /> If APPLICANT is not thO MLP PARTY.PrOOf Of alith0tiZONOn tad IS reqUIMd Title <br /> AUIRQR <br /> INF0& E9Y--' Wh an 11001 cable,1,the ownor or operator of the property located at the <br /> J"=MM_RELL&M— M-- <br /> above site address, hereby autholizie the tticase of any ad all result% gootechnical data and/or onvironmentAINitc assessment <br /> information to the SAN JOAQUIN COtNTY ENWRONMENTAT,T-jr.AL7w EmpARrmENT as soon as It Is 2vallable and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE Mum= <br /> AccWM BY: EMMOYMO: Win <br /> Ass(lNrio-ro: EMft0VLT.III: DATE: <br /> Data SerWee Cornpleted (it already ountplalfid): ConE PIE.. <br /> Fee Amcuft Amount Paid -Iftyment Date <br /> Payment Type Invoice# Check# Recolved By: <br /> EHO 4"2.028 SR FORM(Golden Rod) <br /> RENASED 1111712003 <br />