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SAN JOAQUIN COUN-ry ENVIRONIVI>ENTAL HEALTH DEPAKI-MENT <br />GERVIVE RfP.fl11IWQgr <br />Type at Business or Property 1 FACiIJTY ID <br />I."nr ate'+ <br />4 <br />yiCEQUT <br />OWNER/OPERA <br />L,Lr i n r—L.r <br />CXECKd 91wNG Aoottesa <br />FApLRY <br />SITEADorttss X37 <br />�1 • <br />W ; 150 fj i�tJ <br />Z►rkk vn 9520S' <br />fVaa�Nurr6ar <br />raenen <br />stn.ae <br />HWM or 10A1uRGADUREU (if DWMCWR *am SIW Address) <br />CITY sn.r+r Nwa4ar <br />s� Name <br />STATE ZIP <br />9 i 3� E. <br />AMY <br />I5 I -13D -� Sz- <br />1112EAPPLICATION9 <br />� / �t <br />E 141- <br />7 `i G'� 7-3 44 <br />SOs DISTtticr LDCMr>otiCODE <br />BUSINESS <br />4111�I JL XA1- L UK 1 bERVIC;E <br />CHFCKIfBuuwCADQ1A &&❑ <br />f. En. <br />. - • ._.. .� X07 't'lo Y - L•L.l l <br />Hatteor ADDRESS <br />iAX#�Y) <br />Zr <br />CITY L S rAYE 1A IP G G2-, <br />Rl1 Y IPd1 A " L !?-A' ENT. 1, the dmdtrsWICdi PrOWly Or buciaesr owner, operator ur authorized agent of same, <br />acknowlcdge that all site and/or praim't specific E�tv=wmENTAL HRALTH DEPARTi,4l?N7 hourly ehatgcs assodsiated with this projccl <br />or activity will be billed to We or tqy btlslilless as identified on this -form, <br />1 also ccrti4 that I have prcparad thie applicatian and that the work to be performed will be done in accordance with all SAN )OAQUIN <br />CotrNTY Ordinance Codevr Strmdurdr, STATE FEUE aws. t� <br />APPLICANT'S SIGNATURI�: DATE:0FL " / 52 — 2--c1'•'� (/J <br />PwwrrrY/�ttrsrivS.ssOvmck OPMATO I"AGER ❑ OTRIMAUTTIdxtMDAartirO <br />IJ APPLICANT is not the BILLING PARTY Pmaf 0J authariCatioa to Sign it reyAdred rifle <br />AUTHORIZATION TO RMLEASE INgOWATtON, When applicable, 1. the owner or operator of the property located at the <br />above dtt addresllr hcrtby authonixc the release of any and all results, geotechnical date, and(dr en� ssasrmanl <br />infornu;ion t0 the SAN JOAQUIIQ COUN'PY ENVIRONMENTAL EiFALTH DEPARTMENT as soon as it is availabtdt£hC <br />provided to me or nt r EC�rki {e�ime itis <br />y t�resentapvt. R <br />7Yv< ac Stc 15 REOumeD: Oa <br />cor 60m, - <br />APPROVEDDY., l EMPLAYEEv: � 7 C <br />AtiSIGNEp T17: + - rt al EMPL[1YEE N: <br />Dam Senile. Compteted (if already cornptetiad): <br />SERM CooE: <br />Fee Amourn: ----�Amount paid <br />7 C/ 1$.-2 q, 0 l7 Payment Date <br />Payanant Type 1/ Invoiced Check A s% <br />EHO 45-01-025 <br />REVISED 6.5.02 <br />T8 39Cd 9NI�133NISN3 a3 -lVA S99Eb9P60Z <br />a'd 2i1T0Tib660z H9WIS H39WIALJN <br />SAN JOAQUIN COUNT`l <br />EN\jIR NM04 MENT <br />HEALTH <br />DATE: <br />DATE: <br />PIE: <br />a l{ <br />Received t V: <br />SERVICE REQUEST FORM <br />7:01 b00Z/LZ182 <br />EOE:OT i0 LZ 2nd <br />