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01 v 04 2011 9: 00AM LASERJET FAX p. 1 <br /> Iff IN IN <br /> 10101 <br /> SMIJOAQUIK COUNTY ENVMONMIGNTAL MALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typo d Busty w or FACILl1Y ID S SFRM iiGKJEST# <br /> OWNERi ofEf;r►rtaR <br /> .~ n 1'"Me OA-063 " <br /> FACIM WE L�rc a t tt-t 41W" ° ' <br /> rt <br /> s��Z Nf w4s�t Sr ST•crcT� ys2o� <br /> 14morUmmAwan Iff cwamatftjm5ftAftftQOrATe <br /> mlµ/ p .httr <br /> Cffr <br /> r` Z8 <br /> pHowl" APN. L mD Use Appurw a a <br /> c 1 Qj 2 ? <br /> �• Im 31rwa= <br /> LwATm cone <br /> CO ' /SERVICE MQUESTOR <br /> raMESTOR <br /> i <br /> &Minus NAM "Wo�ST +/-R 37�r HowarMumAmMufi <br /> s 2 Ulm <br /> 3s� F #(,) 420- 43 <br /> cry SA-C(kW IrWN s MPE 3 <br /> MILLING ACKNOWL�pCLrtWM,- L the ung- piny or bminess owner,operator or sotk <br /> agent of e9 <br /> 8ekn0wle4ge that all situ rWoc project speeffic ENVMONMEArtAL HEALTH DEPARTMENT hourly charges assodated with this act <br /> or aWvity will be billed to we or soy baAness as Identified on this farm. <br /> I also owdfy tba#l have prepamd this application and that the wci to be performed will be;done In accordance with all SAN do <br /> COUNTY Ohfinance Coda,S ATS andyw ` <br /> APPLICANT'S SIGNATtr.B!»iw': rff I F� - DATE: 4 Z®tr <br /> RTr/hart Ow tTrnAw a/"Acea d 0M.a Aursomm Aoaxr 13 ,fr <br /> YAPPUCWT is nw rhe=Aw ParY pr0af of ea;rA n to s1p is aq Titre <br /> ALCOR►?" LIM M ULM=rnipe^a�l2t4twt4t �i When appllCable,I,the owner or operator of the property lcc�d the <br /> above sit® address, authorise dee release of any and all resuhs, ical data and/or environumtalisite ass t <br /> m <br /> info afion to the SAN JOAQUIN COUNTY ENVtROKNWTAL HEALTfi DEPARTMWT as soon as it is available and at the wane it is <br /> provided to me or nay repreaeanative. <br /> TYPE CF <br /> RUSH 'RUSH <br /> Acamw BY: Q L t t1 F—t Esmr wm#l: 032-4 DATA `® 7 <br /> AmmDT°: v s #: C L+2-f OATe `( 4( <br /> Dab swvfeo c (f _ ): Sit ole �3 F�e:��� <br /> Fee Anaoaret: ZZs vC P- = 62— Aawarrt Paid (�2. Payrnernt Date !f <br /> Payment Typo CkY, lnvolce ie check 0 Re ce#w d Bp: <br /> END48-0-Mo l PAYMENT SR FORM G <br /> P&VOED 11/17120M RECEDED' ( ROM <br /> - 72011 <br /> SAN JOAQUVN COLJN f <br /> EWRONMENTAL <br /> HEALTH DEPARTMENT <br />