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JOAQVIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICF-, REQUEST <br /> Tye artiness or Property <br /> FACILtrY ID <br /> sko --� <br /> R/ T <br /> CHErK it EYJLjj,4Q <br /> FAWrY NAME <br /> 10 <br /> StTEADmEss <br /> HOME III from Site Address) <br /> CITY STATE ZIP <br /> P <br /> AP # LANo Use APPUCATION <br /> V4; <br /> SOS DiSTPJCT <br /> COCTOR l SERVICE REQUESTIOR <br /> REQUESTOR, <br /> If 01W.A.....ri I <br /> How-or FAx# <br /> cay <br /> 75P <br /> RJLLING ACKNOWLEDGEWNT: 1, the undersigned property or business owner, ofierstor or anthorized agent of's <br /> acknowledge that all site arid/or project specific ENVIRONMENTAL 1-�PAj-ni DEPARTMENT hourly charges a,.�soc-ialcd with this project <br /> or activity will be billed to me or my business as identified on this forret. <br /> I also certify that I have prepared this application and tha rk to be performed will be done in azcordanct with 411 SAN JOA(,!UIN <br /> COW,iw Ordinance Cmies,Stu <br /> 51"n STATE Mid F 1A <br /> APPLICANT'S SIGN ATU <br /> Op TOR(MANAGER 134 -YrHrk Au"I'trogwD AGE , <br /> APPLICANT is raat t P)B3" J "-"p <br /> Primf 0j,alifil orization to vign is required Title Title <br /> LOHL3,CAST.IN RMATION. When applicWt, L the owner or operator of the properly Imcate <br /> above site ad4ress, hereby authorize the release of any and all results, geoteclinical data andior environmentatisite asSessluent <br /> infotrriatiOO to 1111%SAIN JOAQ1 IN COUNTY ENVjR(jN: ,IU:NTAI,.I lyw:rn DEPARTWN-Fas soon as it is available and at the same titre it is <br /> provided ts,)tne or my representative. <br /> TYPE of SERvicF,REWESTED' <br /> )CAY-A '7`1 PAYMO T <br /> R A 14 <br /> sir i <br /> ZNTY <br /> FNVJN' <br /> EPA, <br /> AccepTzo By,,* <br /> AssioNto To, DATE, <br /> Date Service C- <br /> ompleted (ff at SeRvicE WE:C <br /> mody�com �- P— <br /> Fee Amount: Amount Paid Payment Date <br /> Paynwnt Type <br /> Invoice# Check# ecelved 6y <br /> EIAD 48-02-OZ5 <br /> i. U FORt <br />