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i <br /> 61hii-31. 20031: 4: 11PM164"I' Mr ENG•&ENV.CTCG. INC•n"'""N""N'M` "" '" No-4633 P . 2/2 <br /> SANJOAQUINC UNrYENVIRONMENTALHISSAL'171IMPARTMENT <br /> SERVICE REQUEST' <br /> Type of Business or property FACIM 10 tl SERVICE REQUEST N <br /> 63767 Oh -�z 1n35 <br /> OWNER/OPERATOR E] <br /> FAMET RAME — <br /> I` <br /> SITEADDRESS p�/a S', n � �% U, <ST/Lill ZC(� <br /> I e Num r /-Y N <br /> NomF or MARmc AvaRess Ut Daletmt from Site Address) <br /> CITY _ .. STATS ZIP QSZ� <br /> �TDG IC TBYI Cl <br /> RR*. APN I LANA USE APPLICATION if <br /> wa!! <br /> �PMNE 12 Pyr. DOS DISTWCT t.oC,.M,cone <br /> l <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR ,- CHVCXJf81tUHGADOfi00 <br /> �J J�Hmo S <br /> 0U 55 NA 7535 <br /> moMEorM GADDRESS FA ^ '/ <br /> �c�(o ( 6 ) v1�C>• — 7oZO� <br /> CITY STATD :ZIP 9 <br /> 13ILLING ACKNOH'LFDGE : 1, the undersigned property or business owner, operator or Authorixed agent of same. <br /> ackoowledge that all site and/or project speciric LNvI20NMENTAL UPAr 7R DEPARTMpxv bnurly charges assecialed with tris projecl or <br /> activity will be billed to we or my business as identified on Ihls form. <br /> I also certify that I have prepared this application and that the work to be performed will be dont in aceonlance with all SAN JOAgUIN <br /> COUNTY Ordolatce Codex,Slaldai* STo and From laws. <br /> APPLICANT'S S'I'GNATURE: DATrs: <br /> PROrn([TY/IIU5IN6a9 oWNaRI� Or�aATGRI ANAnPJ( ❑ Onlay AVRioRAT$b AogNTI�� <br /> If A✓'HUCANT is Ito'fhe HILU1VC PARiT:Proof of aul horizariorr to sign ir,rcgoirtd Till+ <br /> A> nj()RI7-ATTON TO RELEASE INEQAhj TION: When applicable, 1,the owner or operator of the property lOcatcd at the <br /> above site address, hereby authorize tho release of any and all results, geotechnical data and/or environmentallsitc assessment <br /> information to the SAN JOAQUIN COUNTY ENv180NMBNTAI,♦;IF,ALTH DllrAttTMBNT as soon as it is available Bed at Glx same lime it is <br /> provided to me or my reprountative <br /> TYPE DF SERVICE REQUE$TED: t',{51 /��1'lQU�L fir•rl� pPY �v�� <br /> COMMENTS: <br /> SAN 3�"2p0�r <br /> G� 5 <br /> SPN`ONj SPPN^Er°�,a <br /> APPROVEDBY' / EMPLOYEE M: �Ip 9F9 DATE' Of, 3 /—63 <br /> LFOG <br /> D TO: <br /> EMPLOYEE#: CfL ATE 6�J I—V <br /> rvice Completed (it already Completed): $Ea 03 PI'E a,3Q <br /> ount: Z(D,7Amount Paid 210 '700 PayrMnf081%. f-3e—,3dt Type Invoice# Check# ��f$3 Received By: > <br /> SMILE REQUEST FORM <br /> can en.m sus <br />