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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />COINTRACTOR I SERVZCE REOU
<br />FACIEITY IQ it
<br />SERVICE REQUEST#
<br />BUBINE3s NAME RB ENVIRONMENTAL, INC.
<br />! 209
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<br />OWNER i OPERATOR
<br />q FAX
<br />SAID ?OAQUIN COUNTY PUBLIC HEA.I
<br />r H SERVICES
<br />tai fG»K!r 81LLiyC v'aDlt_�5�
<br />CITY S T OCICI�caN
<br />STATE CA
<br />Z1. 95215
<br />FAMT RAVE
<br />SAN JOAW rN COUNTY FUBU.CH HEALTH SERVICES
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<br />CITY
<br />STATE ZIP
<br />FHCHE?l tom'
<br />APH N
<br />LAAO UYt rAlamx::A.1 IDN 9
<br />209p 46&3400
<br />155-L5a-O60-000
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<br />RE4iuESTaR P.QN E4�RBt=R
<br />BILLING ACKNOWLEDGEMENT.
<br />alt[»K ILL14(: Dil!_'15
<br />BUBINE3s NAME RB ENVIRONMENTAL, INC.
<br />! 209
<br />932-DEIM
<br />HomxorMAtLwoADDRESs 4460 S. HIGHWAY99 FRONTAGE RD.
<br />q FAX
<br />(206
<br />9324610
<br />CITY S T OCICI�caN
<br />STATE CA
<br />Z1. 95215
<br />- !, the undersigned property or business owner, operator or authorized agent of same,
<br />acknledge that all si*e andror proyact speck =rr<<iRo»!r+`r.wFa. HE�L�I-I Q��»;Tre1r houril� �acy� assor�atrd with phis pra�ct or
<br />activity vjll be bill_1 to me or my business as identified or, this form.
<br />!
<br />also certify that I flava plrepured this application aand that the vorork to be performed vril be don= in accardanOiee viiYn a!1 S.+ua Joac,;.t�j
<br />Cc+_�• drdinanca Go�I.s, Sfan�.ds, STtTE and FE�Is.=v.L latiys.
<br />APPLICANTS SIGNATURE 5/,,�f '?, f�,,,I 07`17)2 0
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<br />�' _ nN. r. DATE:
<br />PROPERTY IBLrBINESaOWNE.Ft❑ OPERATOR I MANAGER ❑ OTHER AuTHoarzEoAoENT ❑
<br />Ii,aL=r%r;A*aT is rrat the prooFofauzhorizado,n w zign is required = zrie
<br />AUTHORIZATION TO RELEASE INFORMATION: When .applicable, !, the owner or operator of the property 6xa�i at the abolne
<br />site address, hereby authorize the releaEe of any and all results, geotechnical data andfar environmentailsite assessment inforrna6on
<br />'to the SzAf4 JcvtouIN Cc.unnY EK,1 R6t mEUTAL HFj�LTF? DEPARTMENT as 900n as it is available and at the same f s if is provide e or
<br />my representative. is, ti
<br />f 5EFi410E RECduE 5fE?:
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<br />AcaEP 1=a SY: � � � / E;I,IPLOYEE ii � Das>« 7
<br />12441Z
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<br />Date Service Completed (it alreadycompleted): 5_ eCact 6 �2
<br />Fee Amount Amount Pai Payment Date 7/2 .
<br />Payment Type C� I lnvoice�
<br />19D 4&U:2-0254&U:2-025
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<br />Checks /0 2q3 b
<br />By:
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