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Nov O'7 14 02:44p E] ii IV Contactars 120946342 p.2 <br />SAN JOAQUIN COUNTY ENVIRON1V1MNTAL REALT 1: IEPARTMENT <br />SER'V'ICE REQUEST <br />T e of Business Dr Pro . FACILITY ID # SERVICE REQUEST # <br />Ld Ric (t I <br />OMWR I OPEr2ATOR e <br />CHECK ifBIt.LING MDRESSnr <br />FACrIJr1'NAME <br />SrrF ADDRESS VAM66 wk <br />S� — <br />Sftaet Numbar coon me <br />Home or NLa1LiNGADDRESS (If uirreront from SRO Address) <br />- - SVaer Number Sfraar Name <br />PkrONE #1 eiC- A PN 0 <br />I } _Z 4I - 30 <br />$TAT; 7 <br />LAND Ii APPLICATION# <br />Now 92 EXT- BO5LII: MT <br />CONTRACTOR I SERVICE REQUE 'OR <br />REour=STaa <br />BUSnrEss NianrtE _ I Ilk E, ISL 00 <br />HOME or MAiUNG-ADDRESS <br />2 Coda <br />LOCATION <br />CITY � � STATr ZIP <br />BILLING ACKNOWLEDGEMIt' Ni: I, the undersigned property or business owner. Derator or authorized agent of same, <br />acknowledge that all site and/or project specific ENWtONMENTAL HEALTH DEPARTMENT a rrly charges assoeiated with this project <br />or activity will be billed t© me"ot my-baginess as identified on this form. <br />I also cer* that I have prepared this application and that -the work to be performed wiR b:; I ane is accordance with all SAN JOAQUIN <br />CouNTY Ordinance Codes, Standards, STATE and FEDHRAT_ laws. <br />"Pl ICAN IS SIGNATURE- z .TE: <br />PROPERTY1BUSINESS owNFR13 OPERATORIMANAGIM IJ OTniaAuTTioRusDAim 1 1'Q} i l c9 Ti 3 <br />--..._ _.._dfAPPLXAVT-iT nothe-_ 9kWaP�= proof- of-gui wrizedon to sign Is regiri <br />AU1&qgRATION 19 ItELEA#SE 2nRIIIIAn9_N_: When applicable, I, the owner n Iperator of the property located at the <br />above Site address, hereby authorize the release of any and all results, geotechnical Ja I and/or environmental/site assessment <br />Information to the SAN-IOAQUIN'COUNTY:L-NVMONMENTAL HEALTH DEPARTMENT as soon a it is available and.at the same time it is <br />provided to me or toy representative. — <br />" th <br />TYPEor ED' vyhA btl ne-) re-5�tc� ' 3 <br />aL <br />c.,iFhFAlrNrs: <br />NOV 1.0.. 20% NOV 0 7 20144 <br />SAS JOAQUIN COUNTY <br />FWRPNMENTAL <br />NEALTti1) R ENVIRONMENTAL HE LTH <br />7. <br />ACCEVOgj 35' ERIPLOYEE fC- <br />_._ [� -00E:. <br />r3ate_Se -vice Completed [if-altaady. " Plotedj: Saw= CARE [9 PIE: <br />3 <br />Fee Amount © -� Amount Pa 39j 1)0 P<iy/ Tera Date r r <br />Payment Type j $ Invoice # C # �>Z Jrl �dS .Z Received By: <br />SR FORNt(Gofdeb Rdd) <br />4�f12=1125"- <br />s <br />REVISED 11/4712043 <br />