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SAN JOAflIIIN COtiNTV ENVIRONMEWAi.HEALTH DEPARTMENT <br /> SERVICE REQucST <br /> Type of Business or Property _ FACILITY ID 0 C SERVICE REQUEST# <br /> I <br /> OWNER I OPERATOR 117-1 <br /> t.:Hecx q e1t1.1awa Atx�E:sstJ <br /> 144-flu `(Ili'.I S v I JJ(J <br /> FAraLm NAME <br /> 'J A"> LL rig u9 .4 >J�t <br /> SITEADDRESS 1gtr'7 <br /> :Irnot N11mbnr I cer-m city C <br /> iivmcui ITIMUNU;wunewb Invrnarnntfromane)%uorossl i <br /> _ 3ttrrit Nun aor I stroll Natrg <br /> C7TY STATr ZIV <br /> lit I iL-i-t I\' 1 I <br /> ±nl:r_$� [•.I I APN 0 L4No USE APPt.ICATION 0 <br /> r� L <br /> Rtc%r 02 C[T. BOS DISTRICT LOCAT7CN CODC <br /> CONTRACTOR SERVICE RE,0I IU STOR <br /> REQUESTOR <br /> —Nn <br /> .I Cxeex M Blwr�o Aot�Ieetas <br /> BUSINE99 NAME P►gMEN E"T <br /> st;:� tt-•�sa�T�rtt►,t _ <br /> HoMr:or MAILING ADDRESS FAx0 <br /> f <br /> CITY STATE + LP q 5 SLC!! <br /> Hi Lj,`!N(_dCKNOWLELKiEMENT 1, the undersigned property or h►tsineu owner, operator or suthorked *put or same, <br /> acknowledge that all site and/or project specific ENVII(oNMa ri.M.ftl,*Al:rtt D11PARTMILN1 hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed sill be done in accordance with all SA•N A)AQUIrJ <br /> t'C1 xry Ordinance(*odes.Srandartts,SI'AI�and ft'IXRAI.laws. <br /> APPLICANT'S SIGNATURE: DATF: I <br /> PRarelrn'I(tlt>r1NR.Vv f UNFRQ`` 0"ixMR,/MArrAV. R ❑ Onir.R AtmttaRtxPD Acen-r❑ <br /> ljAPru(-.4xTisgar the Nr uNiGP.aRn-prayjajautharizadon ro sign it rtquired rlr!r <br /> AUTHORIZATION TO RFl&A5,F INFUMNIATION: When applicable, 1, the owner or operator of the prnperty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br /> io. ..... SAN �.. •...... � rr.... rr.� <br /> iuw.uwuvu tv t w wu+sGi.�.l'•,u� iNir..s �.tr iinCiiw.us.vini,unru.ili ur.+ru�ilvia~:.i as biNlu na nk ins aaul� iull� Ii IJ <br /> provided to me or my representative <br /> TYPE OF SERVICE REOUESTED: <br /> COrrENT9: <br /> , / s 2023 . <br /> ACCEPTED BY: zs2t Y 1' ef_e> EmPLOYEE N: DATE: 2— <br /> I�41Vi�J:itY <br /> TC: ... f_.11/LV I CC t♦, ( -".4. /,0/ '7 <br /> date SWVICe Complet (H already coo,plotl � SERVICE Cone:(D(p� `PIE: l�'m 2- <br /> Fee <br /> Fee Amount: j Amount Paid Paymont Data ? I�� <br /> Payment Type Invoice # Check/ Received By: <br /> EHd 48-02-025 <br /> I �� SSR f M(Golden Rod) <br /> REVISED 11/170003 <br />