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hill 'ON KS.. 910Z' '66 `any ami) PaA190 ... <br />SAN BOAC C <br />1 OUNTY ENVIRONMENTALHEAT TH uEPARTN)ENT <br />SERVICE N�QlJEST <br />Type of Business or ProperLy FACILITY ID'# c <br />ERVICE REQUEST # <br />F&OOt725b1� SI0075(�'�2 <br />OWNER IOPERATO�R�/t y7.1t,p- 1' 1 <br />-`�-` `� r:7EOK ifBILLINr AWRf <br />F^.aiffr NAME . <br />-13� <br />SITE DDRESS '✓� 1 ` 1 mb L) 1� @ <br />-��, E � S eee Numcer Dlr e � . \ y <br />HOME Or MAILING ADDRESS (If DlHxent from $Ito Address) " .. C - zi c No <br />CITY <br />PNON#1 <br />�a�5i -8�iaa <br />PHONE#2. <br />( ) <br />RE"UE2TOR. <br />111' <br />Btl INEse ,AtN <br />HOYE 11MAaJ10 ADDRESS <br />S�L;�Vmeer f S1red N, �p,e ' <br />STATE ZIP <br />Ep. <br />tAEO 1198 APPLICATION i.'~' <br />Ez . <br />g03018TRICT LOCATION CODE. <br />Ckmhri7LUN9DREss[3 <br />FA7:# <br />STATE V\ ZIP^� <br />ci <br />F; the Undersigned grope �qc bu9iness owner, operator or authorized' agent of same, <br />'adrnowledge that all site and/or project specific ENVIRONMENT 'HE DEPARTMENT hourly eharpes 2S80cisted with Project or <br />.activity will be billed to me or my business as identified on fo' <br />1 also certify that I have prepared ppli ion and the the t <br />COUNTY Ordfnahca CodStan S, STAT FEDERAL I e Pe ?d''''ill be done In accordance With all SAN JOgOU1N <br />✓// <br />APPLICANTrS sIGNATU r <br />PROPERTY I SUSINESs OWNER <br />ERATOR I MANAGER' r ..l'R <br />ER AUTHORIZED AGENT Q nqd - <br />IfAPPLICANT r'ssnot the rwN PARry proofOfa orizafwntoslgnisreguIreA A1- n('�M 1tt <br />9UTHORI2ATION TO RELEASE INFORMATION: When appllcabl ., 1, the owner or operator of the proprlty located at tha�abo7?E V,YT <br />site address hereby' authorize the release of any and all results, geotechnical data and/or envlronmentaI10c. assessment inforL� p 9E,D <br />m the SAN JO Live. COUNTY ENVIRONMENTAL HEALTH DEPgRTMr;NT as §pOn ask Is available and at the same }.'a lie it, pr OV ded t0 ma OI o Cors <br />TYPE OF SERVICE RE4UESTED: t- 0 ! lQR' _ _ �AfY SOA IAf <br />COMMENTS: 1 L -CAL k p fN�L <br />FLc pi c t 1 .Je%, CoVe �S� IrNEA-o l .a51 0� rviarkav tlzs ovl. S S AR <br />f�5'�paare. 1��,i 1��ivstr� Ca lae� . <br />4-1 `r -ECr% a \ �> . P: d le �;. TYNc�rknr +y> +n Concre}e_ <br />1�s tea}p!e l \S7, (,e, <br />k�r�)replac� <br />ACC6PTEp BY: <br />1h it D � _ EMPLOYEE 7f:- <br />i DATii: <br />ASSIGNED T0: �, V'/!' , O In/ 7q .MPLOYEE OP +rC <br />Date Servic®completed (If already Completed): DATE: <br />Fee.Amount:- ')�_7(6 SERVICE COOS: S��5 PIE: 3(� <br />Amount Paid 1g Payment Date <br />Payment7ype' Invoice# glZ���fO <br />Check # . <br />Received By: <br />EHD 4&02-025 - <br />07,117/08 _ 'SR FORM (Golden Rod) a■■ <br />" ai <br />■It <br />E0/T0 35tid 85b0 XCW30IJJD T99ZLGET99 Z1:91 9T0z/ZZ/80- o ■ <br />