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$AN JOAQUIN COLIN1'Y ENV[RONNIEN'G11J-WAul'H MPAR"PATENT <br /> 1 <br /> 8F'.RV10E REQUEST <br /> / Type of Business or Property FACILITY ID 9 I �SERVICE[REQ ST q <br /> OWN /OPERATOR/�I �V/j�),/��-1�/.� t',�.p� t /„/ --- ClLatfIBRUNCADODESS❑ <br /> FACILITY NAME ✓aV IA Vl lt"�t/I?)AV(�/6 Mal ket <br /> SITEADDRE55 $115 `5 C 7..>f c"J Ck 4 c` <br /> I Stravl Nm Ser Dlrntlor: _uaot ll:nnc <br /> HDNE Or MAILING ADDRESS (if Diffamnt from Site Addros t) <br /> f1l.n Nrtmber___ __.—�'m4r Nrn <br /> C)" Sf.ITE ZIP <br /> PNONE91 En. APN% ------- L„Ila LNEAPPLIC411Ok it <br /> 61 10 T L4 <br /> PHONE A2 Er+, _ SOS DIM LOCATIONCODE <br /> CONTRACTOR_/5ER`T1CIi RGQ_IPCS'tOR <br /> FRE�",IU,E,�STORCNELKhBILLINGADDRESSINS NAME --- PX ENa< EeT. <br /> E OMAILING ADDRESS FA:<a <br /> _ � 1 <br /> CIN -- STATE — ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned pr'uperty or bushlose Oalfla, up Ya(w or authorized agent of same, <br /> acknowledge that all situ andlor priicci specific ENVIRONMENTAL HEALTH WPARTMENT hourly charges associated with this project <br /> at activity,will be billed tome Dr mr husines ras'.identified on this I'mm, <br /> I also ecrd('y that i have piclizred this T11 sn8 lFat the tva$to be per(n:u;e i wall be clone iu�ccordenee:vith all San JOAQUm <br /> t'ol,riti�TY I_h"dinmrce Go:les,;Smndmdr; v1T d�F�L7 It, <br /> X.AI tL1CAN-IS SK NATURI _ DA-.'ri �� ✓ 1 <br /> i Duir.urT!Rcsl+,r .:Ownsn to .1,,It H..':Inl:, ❑ 09 1 IIE ,kureowRr L Artzi ❑ <br /> 7411�Vjj'::Rrt;proaffujorhoriaddt to sign is roquired r: <br /> A ll1'H0HJZ:A I LON 1'0 RI LEASE IN FORMATTON:When Bpplioable,1,the onoti Or ouel ANN of the prop .ted at the <br /> nb Esc rite address hereby eathour the Tcleiise o1'any and WI results, geotechnie l dNq and, cP;j !.I <br /> fiitolmdoll to da SVJIOAQUINCOUM'rF..`iV1dUNMGM AL 116rU.Tl1 tiAPAATMFN71i5 MOt115111i ne Ly A^^1I� M�A/� <br /> ,ovldcat <br /> dwom ltyrepres-rdidiVF �'1 ,'Y <br /> [TYPE OF SERVICE REICLIESTED: i�c�1�_� --\ L1L.�(\c' S qmm=Nos: NJOqG0ENV/ QU/N <br /> NE" "' NMFNTL Ty7ERTMFNcerrD Bv: i rI' f i-�.�...�� lin;rLOrEE tl.�(iR( DATE <br /> : <br /> ASSIGNED TO: ` --" �Eh:PL .-.f1-_amu DnTE: <br /> Date Service Completed Ira beady cDmplotadj: —� 5ELPIce C`DOE. O PIE: C) <br /> rFeeAmomt; Amount Fmd Payment DateIL —t Type L�� In' voice tl f.IT tack f: / Received By./ <br /> EH048-02-025 <br /> 4�( � { r 1 l t, L ( SR FORM(Golden Rud) <br /> REVISED 1111713003 <br />