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Jan 13 15 02i3Hp Elite Iv Contractors Inc 2094616342 p. 3 <br /> SAN JOA0*4 COUNTY ENVIRONMENTAL HEALTal$EPARTMENT <br /> SERVICE RE9UEST <br /> Type d Husinets or Properly FACHM ID# SERVICE REQUEST# <br /> C t 8792 Seco 7(33 <br /> OWNER I OPERATOR �r <br /> CHECK N 9nLINo ADDAEssCJ <br /> FAmLnYNAME <br /> S ADatEss 19[fit L. I�Ytr�k, lrine l - , <br /> maer IdCl.'iCr1 W 1 tL <br /> �e����� N. C <br /> HOME or MARAS ADDRESS (if ORbrom from site Addy) MR coo <br /> Cm Number 1 Nurse <br /> NOA STATE ZIP <br /> PwNrgl FxT. APMi LAND USE APPLIGATIONI <br /> ( 1 <br /> PHME#2 ':.E-- 90S DIMICT . LOCATIaa Coos <br /> 'CONTRACTOR/ SERVICE REQUESTOR <br /> REquesroR •�7� <br /> Busatass NAME 64% �CiR16 �-T*' PNart# E•,. <br /> Home or MAILING ADDRESS �y L,tat rte.,rap FA # <br /> Cm 5,TLYI-Ol=v111epe- 153"D 'STATE ZIP <br /> BMT ACJMMMFDGF.MFNT: 1, the uaderaigcd property or business owner, operator or authorimd agent of same, <br /> acknowledge that all site and/or project specific EtMRONMWrAL HEALTH DGPAR7MR.NT hourly Charges associated with this project <br /> or activity will be billed to me or my busioess as identified on this fano. <br /> I also certify that I have prepared this application and that the work to be performed will be dote in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance COde,T,Slandw*.STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . DAryys��:(( � �•�-%�� <br /> PMPFATY/Busmtss OwMME3 OPPRATOR I MANACaR ❑ OTR6RAMIORIZEDACr, El <br /> 1fAPPLrC4xT is not the Bamflo PAmr.proof Ofm1h0fiMion to Afjivr is regwireit title <br /> AUTHOR InON TO RFLEA MtMATl0N, When applicable,I,the owner or operator of the property located it the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroamentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY Mgv1R0NM0,rrAl.HEALTH Dh-PARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OFSERwERE4uEsmtl: C. j(lrt, L COU W j') t) 41!;7- f <br /> CO MlElrrS: <br /> RECEIVEp <br /> JAN 13 2015 JAN 13 2015 <br /> SANJOAOLgAIC <br /> Eh,JOAQOONTY :NV1R <br /> ACCEPim BY.; 40A Cy y, L-V EMPLOYEE#; N7 DATIC 1 (� <br /> AsawNEo ro: �,9-2CEG 77 <br /> EMPLovm#: DATE: <br /> ( 11311.5- <br /> Date Service Completed (It already complowa):SUMECOM: I PIE: .230rjOpp <br /> Foo Amount: 3170 -- Amount Paid 39D � Payment Dote 1 I3�15 <br /> Payment Typoj! Invoice# J Chock# 713 5, Received By: �. <br /> EHD 46-2-025 <br /> KewsED 111172003 SR FORM(Golden Rod) <br />