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x <br /> 1 <br /> 1 <br /> .f <br /> 0 New Facility Existing Facility <br /> NeAd 59 <br /> San <br /> Joaqu9in <br /> A ica , ion orm <br /> •r <br /> ra <br /> c- 14 61 <br /> -- <br /> Site. Address City State ZIP <br /> (?52.0 <br /> ppl F <br /> 01 "ter U <br /> SRN - - tonsultation <br /> -- - — • - ---_�. - -- - �- - •- — � <br /> Supervisor District <br /> Type of Service C1 Application for 0 h a nge of erne r � R paFrs or R mOde# T her <br /> Requested Operating Permit <br /> Comments <br /> If mobile f d trUCk Or License plate Number VIN <br /> pumper truckON <br /> E <br /> pes Party AFaciiltyOwner Falift art rn ] ntafL!F or rt <br /> required <br /> 01tng Party acility Owner ? Facility Contact Property Owner - Y � _`.� - -- - • ri;M rl <br /> First Namei Lost name It contraclor, indicate type and livcip fWMtWf <br /> jm rtwa <br /> W C or-4cr VVck S-1-0'krf", CA <br /> Address City State IFS � <br /> IMF 0 <br /> 1 <br /> q F <br /> Rhon Phone <br /> ("I <jq I ; ' � <br /> • M.W�a .... _ !7�-.� Y. _ tea+__ •:_- - _ <br /> 1---�Si Fr•�. . �-r rr — �t _T a+� ���� �,.F�r•1-ice.— '—� _a. +� ��•�ae- <br /> Win Party 13 Pacil� �vr��r � 11 lac;lit Contact �r��e�t ��r � nt�art �r� � ect <br /> r <br /> I~+rst NameLash narne f contractor, indicate type j I r; im ber <br /> �a+_ TF�k—•_Y 1—•ti ...ram —� �a a_ <br /> Addre5s P t � <br /> Phone Phone Email ' <br /> Billing Pa rtV 0 Facibty Owner -- - - IFacility Contact 0 Property Owner 0 Corara.-IftorArchitect <br /> First Name Last name if contractor, indicate typo— and license nu i4r <br /> Address City state ZIP <br /> Ph one Rhone Email <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br /> specific ENVI RO N M E NTAL H E LTH 0 EP RT M ENT h o urly ch a r es Assoc is ted wit h th-is p roj ct or a ctivity wi I E b e billed to me or my b urines s a t if I ed on thi <br /> forte. <br /> i also certify that I have prepared this application and that the work to be performed will be done ire accordance Frith aIJ SAN JOAQ SIN CAit <br /> Standard's, STATE and FEDERAL laws. <br /> D PROPERTY � BUSINESS OWNER 13 OPERATOR MANAGER 12 OTHER AUTHORIZED AGENT ' <br /> 7 ,y 4?025 <br /> Title <br /> If APPLICANT is not the BILLING PARTS p <br /> roof of authorization to sign is required 11�4 <br /> oos4i� <br /> 94�-. d ki <br /> AUTHORIZATION TO RELEASE INFORMATION: applicable, 1 the owner r operator of the property located at the above it addrs <br /> release of are and all results, eotechnical data and/or environmental/site assessment information to the JO IN COUNTY E IR NME 1T fthorite <br /> TH <br /> DEPARTI ENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA IDAS A- 006 7 L4 8(0 <br /> — <br /> Date P E. Fee $ / 72 RecordNurnber <br /> El cash El Check tt Confirmation 11 Pigment <br /> Received By C <br /> Rev 71024 <br /> A 1 <br />