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07A20/2011 19:28 2099421925 MCMASTER CONST <br />III ,. IV Lll I I IVJI1111 VVII VJuVVn V'JVII1) V 1/ T <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SFRVICF RFJOUEST <br />PAGE <br />Type of Bi sinew M Property <br />❑ <br />FACILITY IV 0 SERVICE REQUEST k <br />HONK or 0 WLP*a ADDRESS p <br />.trpkg-p t t' <br />`GtSi` �tf14 ,S'IJJX 2 uta <br />EMP40YEEC TG�Tr DATE: <br />13 JJ <br />-5P\-00 6 3i QO <br />ASSIGNS TO: &dAL <br />+' <br />t+'-4, <br />DATr: fl <br />Date Se Ice Completed (EPlnadywrn~): <br />ClW ER/ <br />PERATOR I <br />CdcCNlr 111-LINGADDHIS <br />FACLPY NA <br />HE <br />Amarmt Paid <br />. <br />Payment Date <br />Sire Aoon $s ! <br />Paymon Type ✓ <br />C <br />Received BY.' <br />HOME or <br />ICING AODRESS (if DiffunasQnnnaMe <br />Addreee) OFFtC-"-P- <br />ZYA-40,- ,5TOW''l <br />rAmto <br />smut <br />CIWSTATEC, <br />7" G��h <br />a+ <br />PHONEPI <br />e'n <br />AYNP <br />LAM Use MtLUTpr6 <br />PRONE 02 <br />�1 - Ear. <br />MOM DISTRICT LOGATION CODE <br />rtAVTI} Ad Tntll / CF.RVTrV RVOIIWSFrtjR <br />RECUE Rf CrcceA9lumD <br />f� �r <br />❑ <br />-C� PINtf �'88Q02 6r <br />BUSINESS NAME lzf, 1F <br />HONK or 0 WLP*a ADDRESS p <br />FuE � O QQ <br />I <br />`GtSi` �tf14 ,S'IJJX 2 uta <br />EMP40YEEC TG�Tr DATE: <br />CmdGiC O -AL STALE c:�ZIP <br />i <br />gIL N ' OWL C T: I, the mhrsiped property or bualaass oWnor, opOrdter or eutAorraed A6enr 0) same, <br />Atknowle Ige flat all Site and/or project SpeCigC ENVAON OEENTAL KEALTN DCPARTNig T hourly ChATP5 nssaoiMod with this eject <br />or octivit, will be billed to me IN my business as identified on this Form. <br />I also ceify that I have prepued this application and that the work to be performed will be done in accordartec with all SAN 7 AQUM <br />COSINTY 3rajolonce Codes, Srdndardr, STATE and Poo llffws�.. <br />APPLC T'S SIGNATURE: C{.�( DATM: <br />PAor1Gr /ImuWa SOwNaO �0 MATORIMANAGEAk Orun AurookiMAGOOr <br />JfAPPUC40 is not Oe AVA PART proof of dNlAoriahen to elfin L rEVIlred Vile <br />UTHO RIZAjIQN T UXXASX PORMATION: When applicable,; the owner or operator or the property Iota nt the <br />Above 1d a address, hereby smthori><c the release of any and all reeutu, Seotedmlcal EIM ardor MwircamcntalAito ass S= <br />inibenmti n to the SAN )GAVIN CG MTY ENVIltOWENTAL HEALTH IDFPARTMEOrt as soon as it is available and at the same t' a it is <br />-- __ _.., __r____ <br />TYPE oF Si RVICE WOUMED: <br />4 <br />CwmENrs: �/ <br />Vrtr�l� <br />ACCEPTF BY: <br />`GtSi` �tf14 ,S'IJJX 2 uta <br />EMP40YEEC TG�Tr DATE: <br />i <br />ASSIGNS TO: &dAL <br />+' <br />t+'-4, <br />DATr: fl <br />Date Se Ice Completed (EPlnadywrn~): <br />SFIIYICE CODE: <br />PI 7p <br />Fee Anne Lint Ip- <br />Cr�j' <br />Amarmt Paid <br />5,7-14(, iil� <br />Payment Date <br />�' Jp <br />Paymon Type ✓ <br />Invoice t/ <br />Check a <br />Received BY.' <br />EHD 4e-0 -025 <br />REVISED 1111712DO3 <br />41 <br />D� ARO <br />ppYMVWORM to en Red) <br />REcENED <br />AUG -12011 <br />5AEJOAQ HJIRONM AL <br />H L4 DEPART" <br />02/03 <br />