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De•o 15 14 Ols56p Elite, Iv Contractors Inc 20946163442 <br /> RECEIVED/ED <br /> 15 2014 <br /> SAN JOAQMN COUN17 E"MONKFMAL UEALTH MPARTMMT <br /> SERVICE REQUEST dRONMENTAL HEALTH <br /> FACkMIDA S <br /> 13,910 SP-W 711`79 <br /> i ClxcaN�1r19DAD0REss❑ <br /> FAtamNARF A <br /> --..... StrAoo*w/\ s�446 :. r =}via' Ul�t�.. .._.. lftl('i C1J'1 <br /> Corr <br /> . HD9E or MAILING Aom&ss (it O"rmrd from Site Ad*.) <br /> STATE ZnP <br /> P1DEIh dr. APNa <br /> (-Vi ) '�'f- 1�N7 773[6- to - OC tAuo usEAPPucA wNs <br /> Pmom#2 W. 905 ow"NGr - LOCATOMM CODE <br /> 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RequEsrOtx �t <br /> %i:rie� �Yli�1�✓ cr�vcnewNGwooaPssO <br /> �rISInFSa NaaT6 � �� ,�-, �, p�gi /• / . L� '�Pir, <br /> Hone or mAruNG ADDRESS. FAnt <br /> �' srATs LP C�J�Q� <br /> It11 I ING ACICNOWLE➢GFL; I,the undersigned property or business owner,operator or authorized agent of same, <br /> ackDowledge that all site and/or project speefGc eNMONMtNTAL Hp_ALTIT DITAATmrNT hourly charges associatcd with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performcd will be done in acco daucc with all SAN JoAQt1TN <br /> COUNTY Ordinowee Codes,Standards,STATE and FEDFaAL lawl[ <br /> I �1 a <br /> APPLICANT'S SIGNATUIR6: ✓i Dw7x: I Ct ! J <br /> 1 Vic— rry <br /> PROPElUnVIBUSENr4LSOWN,mr] 0m voa I MANAMIX LJ DTnaeAOntMmal Acnrr[3'" % lr/u10/• <br /> IfArrvCatrT-k norlheB(C✓_It✓GPARTY_ sign,is r"aiped <br /> AUTHORI90I0 TO BILEAR 292DBa &U-01v:when applicable,I,the owner or operator of the property IwAted at the <br /> above site address, hereby authorize the release of arty and all results, geotechnical data and/or eaviroomenbUsite, assessment <br /> ....-.__..drilbrmatian to the SAN JOAQLnN COUNTY ENVrP.ONMENTALHBALTII DaPAKTmtttrr as soon as it is available aml at the Same time it is <br /> Provided to oro or my representative. <br /> 1YK0FSERVIMRFQUe5MW 1 ' 7 LST 2 PAV. NT <br /> I�� <br /> Cer tEo <br /> 1 014 <br /> A . _. rarPcor�kc' a�T I L.... <br /> 114, <br /> _DATE: <br /> Data 3erelce Completed (M ahaatly.DptnplayfQr.. „SOMMCnDe . (, O PIE: <br /> Foo Amount ct0 Amu Pa O <br /> 3eM.D(� P.Im Wd Dab I /Z / <br /> Payment Type �' involae d ISI aICiY lnls 71 1 <br /> R"SED110`172m3 SFt FORM'(QotlrrnRdiry .. . .. . <br />