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:t3Bf19/2dHa� 85101 2094683433 FHD PAGE 01 <br /> SAN 10A QUIN COUN'T'Y ENVIRONMENTAL$I;AL1 R DFYAYL'.rM1iNT <br /> SERVICE REQUEST . <br /> Type of Buxinell or propgtty FACILITYA,t) SERVICE REQU t <br /> OwNE ►uroR <br /> (,.•�,(�- i <br /> FALAJ1,I'SIrE AntrNEsNoa or WiLiNti ADDRESS (lf Dlfforenl hvm BIN Address} qClnSTAYH { <br /> pHta1A1 M APN i WIP Uae APPLICAT011 K <br /> i I <br /> pko>rr>Kl �+, 0 6ST1401 �,+,••� L ATIQ CCao, <br /> CONTRACTOR!SERVICE-REQUESTOR <br /> PLPoUPSTDA <br /> CNrcx tPjyg <br /> guslstasa NAhtt�. � _.. pkoNE <br /> NonsMJULuiq AcDAF118 Q "7• -� �1 z s G� 7 <br /> ,otrr ST�Tt: �tP ,G'` <br /> 1, tiro undertIg isd proporty or bUS1093S owner, operotot or uutlsoriz*d agent Ole, <br /> arkrtowledge that all sl(4 and/or pro}oot spatula WnRONWNTAL l•REALTH 1)PPAMIAWT hourly chargee assocl�tod with L)js yroject <br /> or atiMiy will bebUled to mt or my bttsinas as JdantlRed on this Paan, <br /> I o150 errtlfy Met 1.have prqued this applicadA rood this rho titres peribrmod will be done In acowdence with all SAV Jo„QUn <br /> COUNTY O►'dJVnee CodeJ,Srondaror,S•r 118itA1, tW <br /> APJ'LICANf'S SIGNATURE: fah,?81_ 1 b <br /> PACPTRfl'/EU5tNE97OWNZ10 Or1A,'TOB 14 1A Cn-nrAAtttvoturcuActNrC) <br /> If AP/LlCANT/s nOt the�f j LINaPAR7Y,pr uufhortza(�on ra r1,�n!s requLeC ? ;rug • <br /> AUT QIUZATION TO AELRASE 1MRMRTroN; Whoa app►lcabl¢, 1,the owner of operator of tho property located el tha <br /> above site rddress, hereby tiuthorlse the relesee of any tired all results, geoleeWcal doto and/or enyleonmentnllsite assessment <br /> informulod to Iht SAN JOAQUA4 COUNTY ENv1RONWNTAL HEALTH 06r.+n7-4MT_es la0n as It is avAllsbI4 and to tbo same tiroc It Is <br /> providod to nio or m topresemativc, <br /> 1'TpC o►5eRVlot RCgV81T60c ___. <br /> ACcepT@D Brl ELiPL Mt III! DAM <br /> A"GN90 T0: trMKOM Mt 0411; <br /> Data Service Comploted lir awmady nampteadit 9lftviCe cots[; P r E; _ <br /> Fee Amount' Amount Paid Payment Data <br /> Gaymant Typo Invoice 0 Chack is Raootvg4 By: <br /> REVHD <br /> �E0 IM SR F'ORht Golsen Rotl <br /> REVISED tl17RDD3 i } <br /> .H�rl ,TV <br />