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Li <br />03/22/2002 FRI 14:59 FAX 9146 9683 Wayne Perry Inc. <br />caavtr.F araut=sT <br />.la 001/003 <br />REQUESTOR <br />BUSINESS NAME ` p <br />MAu.INa AooR9$S '-� c�> <br />GVMINAI.IWMIJCMIIVGrv_KV'--- — <br />Friff 'KIM <br />PHONE # <br />a"& I in C/ 4 ` / <br />FAX# <br />EwNri PArm O <br />ca <br />CIT - — — STATE <br />Zip <br />�!S 1 <br />BILLING AC WLED ENT: L are undersigned propaq or business ownar, operator or aulhorkmd agent of aama advrowled9e drat all site andlor project apecfic <br />RU9U, KF T" SE�vm Ew Rpmeax HEALTH Dmsoti hourly chames awod3lad witll d1lS projad or stdviy Wn] he baled to me Or my hu5ineSs a9 idenafied an this lortn <br />1 also oardl that I hav8pnwared ViS apP6mi tot tt rated WPI be done In amorda= with aA SAN jaAaow COUNTY ordinance Codes. Standards. STATE and <br />FEDEfWI.13W3. <br />DATE: <br />APPLICANT &GNATU <br />PROPERTY/ BUSINESS OMER 13 OPERATORU <br />A <br />TOR KA R ��`'°,.� d OTHERAtrn AGW op(Z'�l �C � Q� fa�� <br />ITAra.C.Wrarot protr@rok0 <br />rtmdan4FISI avind litlt <br />AUTH RATIO REL INF MO : When apprQble. L the owner or operator of the property kxzM at the above she address, hereby authortm the relem of <br />any and all re TIOub. geotechnical data INFarKYenvhanmenraysite assessment informadan to the SAN.IaAML4 CgUNTY p%" HE&TN SP�ty MS ENvs Iqw-NTAL HEAL'W DIVISION 33 ao0n <br />as it is avail8ble and at the same time itis Provided M me or nw represer t0". <br />TYPE OF SERVICE REOUESTM /-jQ P% ,,4 - _ 6)n /74� <br />CoaMemm: <br />APPROvEO HY: t <br />ASSIGNED TO: (� <br />Date SeMca Completed (if atrsady completed): <br />Fee Amount <br />Payment Type Invoice g <br />COMVACTOW! <br />EMPLOYEE#: <br />Amount Paid , <br />Check # <br />DATE <br />SERVICti CODE: <br />payment Date <br />ECEIVED <br />SAN JOAQUIN COUINT'r' <br />PUBLIC HEA ?' °'IWT' <br />`FOltli+/IENTA <br />o z— <br />Received By: <br />