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Type of Bu i <br />r <br />OWNER / O <br />FACILITY NAME <br />0 0 <br />SAN JOAQUIN C.o11N 1 Y k <br />;NV11t(N <br />)Mk;N'1'AI. HI;AI.;1'II jW,1'A1tTMFNT <br />ness 4f Property <br />SITE ADDRESS <br />RAT'R <br />o -zk <br />SERVICE, REQUEST <br />FACILITY 11) # SERVICE REQUEST # <br />ai ®� P63 <br />CHECK if 131LLING ADDRFSS <br />V/Y1 <br />t,7) <br />HOME. or MAILING ADDRESS (if Different from Site Address) <br />t --1 -K `7 <br />GnY <br />PHONF #1 Ex r. APN # <br />HOME or MAILING ADDRESS <br />Exc. <br />:Z,6`� <br />Sheet Num <br />C"'- <br />L":' -'A-•`• 4t_. �-; In <br />STATE ZIP , <br />LAND Usl_ APPLICATION # <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE 11EQUESTOR <br />CHECK if BILLING ADDRESS <br />I3IC�I,INt: A(;hNU�VI.FI]c:iH:l<4H;N7': E, the undersigned property or business Owll,er. Operator or authorized agent of- sartte, <br />MEs'N'I'AL IJEALT11 I)ITARTMI:N-I' hourly charges associated with this project OT <br />acknowledge that all site and/uI' prUjcct Specific )rNVIlt()N <br />activity will he billed to me or niy business as identllled on this Ibmi. <br />f also certify that 1 have prepared this application and tliat the work to he p orrtled will be dolls in accordance with all SAN JOAQUIN <br />(;(.)t)NTY Ordinance ('ndes, ,Stands ds, S'I'A'rr•. • Ild I't� :RAI. h1i <br />APPLICANT'S SIGNA'1'URK: <br />TSUSINES% OWN[..R ❑ OVIERATt)R / MANAGER ❑ tT[•HP:R A(1T11(')KizF.I) At.t<N-r ❑ <br />/f fl)1PL1(-A1V7' lS not the fl&14A1 f�A1C11, Pro"J Uf Out/lOIYZatI011 10 SIgH is PL'g"ived %'elle <br />AC)'1')E10R1,V,AT10N TO ItE:LLASE INFORMATJO N: When applicable, t, the owner or operator of tho property located at the <br />above site address, hereby authorize the release of any and all results, geotcchnicai data atiii/or environmental/site assessnaeut <br />ntfonnatiun to the SAN JOAQUIN (,o7jN'1'Y ENVIRi)NM)rN'I"AI.. I II;AL•Tii DI.'I'AKTMFN'1' as Myon as it is available and at the sante time it is <br />provided to ine or my reptescutativc. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: APR ? 8 [ 008 <br />ACCEPTED BY: — — -- EMPLOYEE: D <br />ATE: <br />• <br />ASSIGNrD 1'O: <br />EMPLOYEE #: AIS: <br />Date Service Completed (if already completed); P <br />CODF.: <br />/► — <br />mount Paid fir. `' PaynTent Date _ <br />` <br />Fee Amount: T'— <br />r ReceivedBy: <br />Payment Type Invoice # Chock # -- — <br />'. --- - - 4. <br />SR FORM (C: Idem Rod) <br />CHD 48-02-U25 <br />REVISED '11/11/2003 <br />8' cl T OLEZL;s60Z cIHW e T*: T T 80 62 j4u <br />