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r <br /> . SAN JOAQM.N COUNTY ENVIRON:NI'FN'E'Ai,WALT14 DFI'si►R7'W N'C <br /> FACii.TY ID'# <br /> SERVICE REQUEST# <br /> Type of Business or Property <br /> OWNER 1 OPERATOR p � L CHECK if$t LING DpRESs <br /> Fnc1ury NaMF <br /> 51T Anf)RESS �� p c, ►.t R�� <br /> Sir9 .Nun�hn I IQ <br /> s ,. - <br /> HOM7±of MAiLIND AnQRIES$ {tt t3iifor0est frorri$itG Ac9dree0 <br /> 51 ,Niimhar Ira3Ai.N ntn <br /> STATE ZIP <br /> C€-r� CPti `d�c� S"3lrr 1 <br /> LAN SE APPLICATION <br /> rPHONEM Ex; APN# <br /> UU <br /> - -_ <br /> ES ISi'St1CTL.00ATIO Cilt3t <br /> is}iONE i2 .} <br /> �- <br /> { CONTRACTOR 1 SERVICE- RE QUES'�.O�i <br /> rsusnjess <br /> (rQkiL=SORC14i:CKIf1'3kL11NGADDRE8513 <br /> PRONE� � .TfiltltE �1F• G E Nv 1i ,�,ww+EN� AL. ,aifEC <br /> `3h -17 <br /> l,h lAILING AooRESS " LN' Ofk14 �• { 0 11 ' t015-+-A <br /> lfor�il or M STATE C.N a Lp at 7,4b <br /> CITY O'C>k <br /> Ixif�l;l 'O ACIt O dNT: ti the undersigned P�"opOrty ©r busilless owner, Opel�if4Y{tir Itttiltiorr�rll t�tiit rit' �IIIrIc <br /> ackiim led e that all site aridlor project speci#.ic ENVIRONMENTALH8At,TH I�HFr112TMt?NT licsiiily'cli srges assoai iictl with Ibis firtiicat t)I <br /> activity�vili.be billed to me or my business as identified an S}1 .form. <br /> xlsn re>tify ti7t€t i <br /> ave-prepared is application and that the Yvork to be perfortned %vili be doixe in of<:c�rda�>ce Nvitti all SAS 3t�nt�lttu <br /> C4tJNTy U,•rlinance Coder,Stanch Sl'ATB all t .ftAi.laws. <br /> jU PL•tCkN r S SIGN ATU", <br /> PtLOr It I Y/:tius€N KSS CJ�1'Ni R'� r TOFF J 1�JANAOER (TIER.Aiyrr€0I117.n AGr,�v I k .� <br /> rroo 0 atifloar`ization t0�r;>n is required7"ii(e <br /> ifApiv rrANT'is riot the SII i' f <br /> to 1R'f.?�A t:fO :1'[)f213 FA ..� N :tVl. : O :N�11zelt applicablc,Y, tl�e oivtYer or aper aldr o f the Incatcd at. the <br /> LL>ibaVe site actclress, hereby autfiarixe the release of any.arid all t•esi1lts; gcoieclinic.il (latr iirtld1 inaejlr�]Tsitc sssessrne3r€ <br /> information.. to,die SAN joAQUIN COUNTY ENNr[RONMr-NTAL HEAl.TH EPARTMi-I' aS soon aS nt�tl;wt}1C and at tlic 5aitit tii�l�i iE is <br /> provided to wo or my representritive. --- <br /> TYPE OE SERVICE REQ1,1ESTE0: 5ruD PAYM <br /> COMMENTS; DCC L O 2lf 111 <br /> SAN.€OA0NMV-W <br /> ENVTM pEPAF; kk% <br /> EMPLOYEE 0 DATE: l 20 (U <br /> I ,ACCEPTED$Y: (0 L_ D <br /> �C <br /> EMPLOYEE#: © SDATE: ! 2-0 /'D <br /> i ASSIGNED—rd: '-rA S.(O.,.dp C:(-.C-OS PIE: <br /> Date Servita Complatod (if:already complet0d): Sr�1yICECooE. Z2� 2CoD <br /> —, f Amount Paid 1i � , p C� i'aY got Data �(2, 20 (0Fee Amount: `t , 0 D "c <br /> Check# D3 Received fay: <br /> Payment Type �f Invoice# - <br /> 5t2 5t:11;;M(C,ol[iMti kod) <br />