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ROM : I.IANTECA BEACON <br />u@u 5 • CUuc <br />PHONE NO. : 2098249282 • Sep. 26 2005 03:44PH P1 <br />iIL! Jlli F' <br />SAN JOAQUIN COUNTY ENMONMENTALI ICALTR DEPARTWITr <br />SERVICE REQUEST <br />oe BVsta>eW or rrw.rty+ <br />OI%PATM <br />? ) r Q e R <br />SERVICE F Qti BT If <br />see®©�f�ii <br />t:arrct:t�wrA, �� <br />SnAmiss <br />Hats or PAUMc'AWwse (w vh%wt frmle>2 Addmmw) <br />ct>v <br />STAT zip <br />E'R APN LAND USE APPMOATiON f <br />PI-lW#2 -- - BOS tho MG -r L=A'nCN Cott° <br />wr y ,nr Vsv'bo 1 WVIS\Y rr'P T%IPJ VTY—c..ra— <br />ALLi<110 AiCKMW1,& F : I, the undersigned property or buslum moor, operator or aattborized aEetat of sauce, <br />WJM0W18*-d et ail site atd/cr project spooiiio Elq-MONMENTAL HEALTH DaPARTMr-N'sr hourly chutes A99oc4tbed with this project <br />or amlivily Al be bdlcd to tact or my business as ltientified ca this form, k <br />l' alao o:rrtl8j tJ:at 1 hovb prapm�d this application and that the work to be perfornted WLI be done In accordancc with 8 l SAN JOAQUIN <br />1r0i1P17 Y (J�itslulce Carla, .S WAkO "ls, STATE and FLUsltAt.. IAws. / <br />1'a►or tY/ Hu�n�at:kt tltivt7Fit OPB NIVAI MAXAt rA El 0i'x R A11T90 1zW A ar:Mr ® _ <br />YAmoU&M �iqsoot thL, AR44WI&M ~nf orr noArizae om to SIR b- required - - — •rrrr�— <br />A.U.IM-9- B7Q2N 12 AIG[. iT+ilf'1988-A'r : When applicable, 4 the Qv Mar or operator of the pluperty iodated at the <br />8bOVe We eddrM. hKahY sautivnrka the relearn of am and oll r"tilu, Samachnioot J ale end/or onvi��.m ontctt/oit� 4L'00r.,lJ u%;1At <br />ila6orNa140112 to t60 SAN JOAQUIN CMiNTY E NYCRON�j!ENTAL HPA TI! DEPARTWM as soon w it is axiitiblv and at (he same iLmc it is <br />provided to mo or any reptnalcn!n6v0, <br />-Ccltl�rlrs: <br />• RSG <br />14 <br />SEP <br />AID.yONEDiO. r , irIItPLQl7Fk11k DarE: <br />DWA Sallee Cewpletad (If siraWy complaWt: S6ralCc CODE: P E: L <br />--- - <br />Fee oust: Arnou»t PaW $ Palvmont Date a �6 <br />Pt+rrllonl7ype , % irwuic®e Check #. 1tecehred By; <br />EMD 46.02426 <br />REVISED 11112/2003 SR FORM (poldan RW) <br />$ to <br />GOVN4 <br />NENS P& T <br />OE RtM N <br />