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08/19/2002 12:45 4640138 ENVIRONMENTAL H#H <br />IAN JOAQUiIN (,,VUNTXENVIXOINMEKKA.l,k"A.0 k> )ll T: VA.KEM 'NT <br />SERVICE )REQUEST <br />PAGE 01 <br />Type of Business or Property <br />: ° <br />ACILITY ID •# SERVICE BEQUEST # <br />©:0 <br />j . <br />IT Y <br />EAD <br />OWNER I OPERATOR <br />RF-CE(V <br />❑ <br />SEP - 9 2042 <br />CHECK If BILLING ADDRESS <br />FACILRY NAME <br />pUE3LIC HEALTH <br />HEAIJNDNISION <br />n <br />ENVIRONMENTAL <br />APPROVED BY:. <br />EMPLO.'EE 0::. <br />SITEADDRESSODo <br />C <br />EMPLOYEE # ,: <br />A" 3 �."� . DATE.,., ..:q.c. �•y^.., <br />Street Number <br />Di—m.n <br />$tMCI <br />Name <br />Payment Type <br />C <br />Check <br />HOME or MAILING ADDRESS (if Different fror.. <br />Si°a Address) <br />Street Number <br />rktroot N2mQ <br />CITY <br />STATE ZIP <br />PHONE #1 £ <br />APN # <br />LAND Use APPLICATION <br />( c)2 <br />PHONE#2 Err <br />$OS DISTRiCT,t 1 r r <br />LOCATION CbDE��zi <br />CONTRACTOR / SEFWICE REQUESTOR <br />FZEQUESTnR bDrzf?-�.tYf�E �C�7 <br />$US1NE85 NAM -F- STI `' L__. <br />t d f �fYl, <br />HOME or MAILING ADDRESS <br />n( d nE.�� „ W . (I v r �i <br />CITY R, (2r_ � I 0 q-0 STATE <br />CHECK if BILLING ADDRESS❑ <br />' Vo— 70 2, d FxT. <br />ZIP <br />'=.91M <br />ILLTNG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, vperator or authorized agent of snore, <br />peknowlcdge that all site and/or p:-ojeet specific ENVIRON'AENTAL HEALTH DEPARTMENT hcrrly charges associated with this project or <br />pctivity'will be billed to we of m, business as identifod on this form. <br />iI also certify that I have prepar d this application and that the work to be performed will ':ie done in accordant with all SAN JoAQum <br />CouNTY Ordinance Codes, Sta dards, ST E and FEDEi AL laws. <br />APPLICANT'S SIGNATC.IM' I � � _ DATE: <br />PROPeRrY/IayslNessOWNEAE. .OPERATOR/ MANAGER ❑ AGER AuTrroRIZE!)AGENT _ <br />IfBL <br />APPLLCRN7 s not the proof of authorization to sign ; require Witte <br />ATJTFIORI_Z_AT1<ON TO ' .ELEASE INFORMATION: When applicable, 1, the a- finer or operator of the property locatcc at the <br />above site addiress, herey authorize the release of any and all results, geotec',;tical data and/or environrrlentaUsix assessment <br />information to the SAN JO tQW11 COUNTY ENVIRONMENTAL I-IEALTFI DEPARTMENT is soon as it is available and at the same tir,,c it is <br />provided to me or my representative: <br />TYPE OE SERVICE REQUESTED: <br />� � � � � (0AE <br />N -1 - <br />EAD <br />COMMENTS: <br />RF-CE(V <br />SEP - 9 2042 <br />SAN JOP'QU1N COOT," <br />SERVICES <br />pUE3LIC HEALTH <br />HEAIJNDNISION <br />ENVIRONMENTAL <br />APPROVED BY:. <br />EMPLO.'EE 0::. <br />ZZ DATE: <br />ASSIGNEDTO:.' �.. <br />EMPLOYEE # ,: <br />A" 3 �."� . DATE.,., ..:q.c. �•y^.., <br />EFemount: Z�' <br />Amount Pald� 1 , r •: <br />payment Data _ <br />Payment Type <br />Invoice # <br />Check <br />Received Bye <br />�'. <br />EHD 48-01-025 A SERVICE PEQUES-K-®RM <br />REVISED 6-5!02 <br />or <br />