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61/29/2003 08:58 916646ift RHL DESIGN PAGE 02 <br /> 01/28/2003 10:43 464013 ENVIRONMENTAL HE PAGE 02 <br /> $ASV J V,A QUINCOUNTY�.''lNVI RV14MENTAIL HEALMH DKI-WITMLNT <br /> SERVICE REQUEST <br /> Type of Business or property FAQU1'Y to I SERVICE REQUEST 1 <br /> OWNER I OPERATOR <br /> a AaoRrss <br /> Fmm NAM <br /> 'S tlikca44'7 _ <br /> How or Mum,A®mm (it bltierent troth site mdress) <br /> • ' Street zhxr�Ber u <br /> OUT 'STATE, ZIP <br /> Piro iil , EV. APN N LAK6 Wn A"UCAIM a <br /> Pttoae12 a Dos.ftmet 4Com <br /> CONTRACTOR/SERVIM RR MR <br /> REQUIESTOR Q► 1Cit Aan�ss <br /> BUSNESS AAME PH=# axz, <br /> i•IomE or MA IMMESH FAx A <br /> CtTX, STATE G� 7j <br /> RYLTANO ACXNQWj&bgKM8NT: 1, dw undersignad'prolserty or bWom awwr, operator or autherized agemt of same. <br /> acknowledge brat all site and/or project specific SWRONMBITAt,klfumi D9FAK'rtwWrb0uriy aha *tad with this punt Of <br /> activity will be billed to zaue or my husinen as idudified on this form. <br /> 1 also ecttlt',y that•I have prWarad Ibis ligation and that the work to be pmfor ed will be done in accordance with all SAN Jontl <br /> COUNTY Ordhimice'Codcs,Stet , AT a Ft:Dti L Ia�. <br /> q . <br /> APPLICANT'S 5 SI+GNATURM DATE: .-..a- <br /> rnot rxll�t t�► Qwt �t o �ORIi►mAGsu ❑ 0ntziAunxow=AGVffQ`"A&6M <br /> If APPUCAW is iml the&U&t a pAR77s prpe{,Fvf W9fWrAWkn to 4811 iS tsiYed eft fe <br /> AUTI TbRt71'l`I!a �' ,t�. liNlf+'171Lt1Vl.__A'1_t s <br /> applimble,1.the owner or,operator of tie pra located at tin <br /> above site add . hgmby authority die icteric of any til all t't:Sults, potechnical data amwor environmer"Llsite assessment , <br /> jn*madou to the SATO JOAQU94 COUNTY i mn=NmEmrnt.HMW DEPAXIMPsNT as sm as it b availabic and at the same time it is <br /> providod to me or-my ropresentative. <br /> TYPS QF SEWGE RMbUESTEIIZ <br /> APPROM SY. Et .CiYEE DAR: <br /> Ass r.NWTcr fEMPLOYEE : DASE <br /> Cato Service Completed (it already wmplate,q. P t Fu <br /> Amount: I Astoouni Paid Payment baso, ' <br /> Pa,nmcrtt typo • tnvc iw j Cheep# Recalved Dr. <br /> t ttv 4"Is ; SERVKM AE FORM% <br /> RBMED"-0Q. <br />