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FAcn.m,NAVE Levand-Bright Property <br /> BDEADORE35 3 East Eleventh Street Tracy 95376 <br /> 94wINwi r rum". S .w W • CU, ZIPCee <br /> HOME Or MAILINOADDRESS (II DUforenl From Ste Address) 24692 j Sand Wedge Lane <br /> Sn N Ar <br /> C" Valencia STATE CA LP 91355 <br /> MORE L'1 E^ APNV LAMO USE APPLICATION#. <br /> 1661))904-2133 233-369-16 <br /> PNOAE f2 E`T- BOS GSTa1CT LOCATIDNCODE <br /> 1 ) <br /> CONTRACTOR/SERVICE REQUES-17OR <br /> ReDUESTOR CmCN it EN IN.Annsrss❑ <br /> Robert Marty <br /> Bus-Ess NAME ' ' "Ne <br /> E" <br /> Advanced GeOEnvironmental.Inc. ! 209 467-1006 <br /> HOME or MNL--ADDRESS B37 Shaw Road F(10 <br /> (209 )467-1116 <br /> CITY Stockton STATE CA zip 95215 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or hushwls owner, operolor or authorized agent of came. <br /> acknowledge that all site ut&oi project specific EAVIR--NNIRFTYL HE MMI DITARTIENr hourly ehwgwti associated wide dtic ptuject <br /> of'aetwhy will be billed to me of my business ac idcntilied un chis form. <br /> 1 also Celtic,dut 1 InvC prepared Ibis application and that the wurk ca be perfolmol will he done in aCwrdaeu a with all S.1N IOAOVIN <br /> COL'S'lY S %n1 mud F[Dl:a.0 IOwi. / <br /> APPLICANT'SSIGNATURE:—y <br /> Pity I-IJITT19I:Q\ENS owXCR 01-cittiolt e-NIAS.1w;LIt n1111:M:1L"IIWNI%1:0.\4E\'1'❑ <br /> 1Taf'f'L7Cd+'f'is nofrLr BlL(J.\'tiP.lxn.pronfnfnudmri:udon fusign lvrrynirrd Tole <br /> AUTHORf7 TION TO RELEASE INFOR31ATION:N9ten applicable,1.the owner or operator of the property lucaled at.he <br /> above site address. herebv authorize the release of any and all results, cCWedmical data an&ur Cnvirunnun aline :uses menl <br /> infomntlen la the SAN JOAQUIN COLIN-rY LNVIROSNUINTAL HEALTII DEPAILTIENT as Soon as it is available and at the same time it is <br /> pfovided to Ills or my lepfesentalhe. PAYENT <br /> TYPEOF SERVICE REOUESTED: 'EY iED <br /> CONMENTs: FEB <br /> 2014 <br /> SAN JOAO IN COUNTY <br /> ENVIRO WENTAL <br /> HEALTH IDE PARTMEUr <br /> ACCEPTED BY: / EMPLOYEEA': Zb "70 DATE: <br /> ASSIONEn TO: T{�iG4^ EMPLOYEE It: 2 6 CL. (4,q I DATE: <br /> Date Service Completed (Il (ready Completed): SEay10ECDDE: D J PIE: <br /> Fee Alnount: 3 SOD Amount Pal 5�, Payment Date 11 / <br /> Payment Type Invoice 1: Check O 3 g 7 3� I Rec teed By: ' <br /> �T�' OVA/ �A,) U WA�at� <br /> Q C(O`I I C) <br /> ld{��)t <br /> aa� <br />