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INSPECTOR`S SI <br />APPROVED V.. <br />AsuiAsslGNmTO: <br />Date Service f <br />Fee Amount: <br />t. <br />Payment <br />—� <br />VCM L. e <br />(d already completed): sswmcom : C' <br />7 Amount Paid F Payment <br />IftYOiCC T Check 0.1 <br />7-F <br />SIGNATURE <br />IL-( DATE / <br />`l DATE <br />PAYMENT, <br />RECEIVED <br />JAN 2 4 2003 <br />"AN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />Hr^'rHPIVISIONi <br />• •'Pl>w� <br />Received By: s� 1 <br />SERVICE REQ <br />JEST <br />Type of $usines`a of Property <br />FACILITY ID # ,. <br />SERVICE REQUEST h <br />OWNER/ OPERATOR <br />OILLiNG PARTY Q <br />47 <br />Fa iLn NAate <br />• � .l—rte .,� <br />SfiEADGRESS <br />S/.bW TGr/'N4' w"sae�cx�W <br />o�o� <br />/�j� n— <br />�sam <br />/' <br />Mailing Address (If Different from Site Address). <br />(.�.� <br />H- ,nH rev. sc4. x <br />cay <br />STATE ZIP <br />PHONe #1 Exr APN it <br />LANo UsF APPUG' MN e <br />PHONE #2E <br />0$ DtSTrucT ' <br />.'; LOCATION G00E. <br />CONTRACTOR r SERVICE <br />RE01JESTaR <br />REOUEVOR <br />�i / �! �A <br />BwNc PAM R <br />_ <br />BustNusWE <br />PHONE # <br />MMt1NG ADDRESS <br />Ctrr <br />-ST ATI <br />131LUNG ACKNOWLEOGRMENT. I. the undeMs ned property Or business owner, opera <br />PQMX HEALTH SERVICES ErmRONiaEN AL HEALTH Ow Sm hourly draw assodated with C14 pruiect <br />r or Yuthorized agent of same, adowaWge that ad site aadfor projed speck <br />or adN�y wit► be died m <br />me army business as idei� on C1 s trm, <br />I also tartly that 1 have prepared N5 ippGca6on and dW the work to be perfdmred writ be done in <br />i-EDEAAL taws. <br />ao=dance with an -W -JGX 1N CCUNTY ordnance Codes, Standards, SATE and <br />APPLICMTSIGNATURE'4/ 91V <br />DATE: �`y <br />PR0PEiTY/EUSwEsSOwNFR 0 OPERATOR/&WIAW <br />AuTHORIZEDAZENIr ❑ <br />UAPPWwt,:s1ot07o IPwrmprvd <br />UTFIORIZATION TO RELEASE INFORMATION: When appkzble,1..the owner or operate <br />Cf audrorl=dNrtosigrriarvVirld ritly <br />of the property k=ted at ttte above sha address. hereby authorim the [*M of <br />any and aA resutlg geot2d�nigl data andfar emrironmentaUsite mertt Arbrt tlon to the SMx <br />as it Is avdif2ble and at the same time it is provided to me or rriy repnme=tft <br />0AQLW Ca MpL&X HEALTH St- VMS ENvarO ),UIiAL FtFkTrt Drvr3 cN as soon <br />TYPE OF SERvia REOuE=: [� ,n <br />cOluMEtrTs: T// m,� o,.c .� ��/,6,� s� `�/ <br />Cir •-� , <br />INSPECTOR`S SI <br />APPROVED V.. <br />AsuiAsslGNmTO: <br />Date Service f <br />Fee Amount: <br />t. <br />Payment <br />—� <br />VCM L. e <br />(d already completed): sswmcom : C' <br />7 Amount Paid F Payment <br />IftYOiCC T Check 0.1 <br />7-F <br />SIGNATURE <br />IL-( DATE / <br />`l DATE <br />PAYMENT, <br />RECEIVED <br />JAN 2 4 2003 <br />"AN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />Hr^'rHPIVISIONi <br />• •'Pl>w� <br />Received By: s� 1 <br />