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N7J4F17 N/I1 18 <br /> SAH JOAQUIN a~D11N1'Y ENVIIRONMENTAL HCALTH DCPARTMCiNT <br /> _ __ SERVICE REQUEST <br /> Type of Business Cr J°roperfy— - FACILITY N]# SERVICE REQUF.S <br /> - 777 <br /> -3w- Mi;RaTo - - , <br /> C.x�cxlt>dltnlaaoorzs,3 <br /> PACIuTy NAvAi <br /> 76 <br /> Hort v MmAr Aounlass (Il Glnnront froln 417*Addroes) <br /> Slrm Num <br /> Crrr STATE Zv <br /> PHONE q1 - e�• APN W LAND tan AJ'Pt,ICA"ION N <br /> P110NE IJZ A Fal, SO$t'19YRICt LacAnoz coot <br /> CONTRACTOR i SERV.ICE RE,QUESTOR <br /> Ael <br /> R�au�rot� <br /> HavtE or MArr 7SS i/ Fox I <br /> J <br /> u- d4jo,Aj <br /> HI1,I,INC A4EEgNv1xI) ,IFME T- I, the undt'$18"ed Itl•t)�lerty(r 11)"ArlC#S Owner,Optrator or audiorerad agent 4f same, <br /> aeknowtedpe that fill site and/or prujec:t Sttecir1C LNVIRONMENI•AI,141'ALTil Dt:PARTM171'r hout'ly charges nssaciated wilh this project <br /> or activity Ml l he billed to we or my business ay1deniffied oil dl t. <br /> I HNJ3 CL"ilj•Thar I have,prepared Ibis appli-it• t II work cr rated will bo done in=ardarttx.with all SAN JOAWIN <br /> CU[:Nr°r t?rrliJavn'e!t>rJrMv,,�'lptklrn[f.C.S'f '3i it e RA, Wy. C/l/ <br /> ` hPPLIr:AVVSSJ(;iVATURE: _._µ_ms, DA'I'ri: 6 f:10 'fir <br /> r_ PRctMI-i•f UnwNr.�. 01%,rrn LJ Qpttu.tiT48111AMOKA } fFrtrl.N Athtrarttar.0 he;u%rr 13 <br /> .l rrr.rr•aA'r i.;,fru r11v!+r rAr,816-7 pr�r:jvJ�rrHlhvritalinn to afglhis fequlydd Title.' _ <br /> AtJTIlt}RITA:I IO{r 7'O ItI LGAS 1N110RM1IA"CIdN;Wlicrt hpplicable,I,the oiraer or operator ofthe property ICCAW at the <br /> Kbove ske nrJtlrns{, 11c3r.L'; authorize the rejt!Mt of ally Alld rill M.wlts, j;Cpteellpletar data and/or envlt•anincri1$I/site a$3C3STtter1t <br /> inlnrmali`5rt 1,me cIIt�w 1N 1rl,triulil Co IJN'J�'IiN MONAIRNTAl.11PA1,11I UCPARt'MIKI'aS soub Ks it is nvnirable and at the 9onIa t�E-s <br /> proridcd Io r Irl,.roprc9etrinliw:. Y lV <br /> TYPE OF SERVICrf3fWESTEo; L(..�T 7 it F c T REt; _ <br /> sup 008. <br /> TY <br /> SRN 10AQU1N PUN <br /> trTAL <br /> t3VlRdNM jNfENT <br /> —. NEA�LTN[)EPA <br /> ACC P'rkli 1-3Y_ L( L f I r� �MF'WY�S#: L Z r GATE: 7 ! �} <br /> A$SIONF.)TO: V t)A]l! ICL L(_ EMP4•4YEJ: i J 7: <br /> FF",—*,' <br /> COmPluted (1fr lresdy eamplotAdf: Seawearoc6; p fg; oC> <br /> mottnt �`L� Amount F'ald <br /> - �7 1 ' �} r ©� pa entDatelPko <br /> payment Type Invoice# Check 1f Recelved B <br /> tHb SR FORM(Golden Rk�d) <br /> F�V13En 1'.1i7.•2�79 <br /> �OOIti00� TZ MOIR NVS OHXVV 08166H 6K IVA T�T NOE $OOZ/H/90 <br />