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S+:N JAQTi , COUNTY ENVMONMIK NTAL HEAL'}�a DEPARTMENT <br /> SERVICE RE, QUEST <br /> Type of Business or Property FACILITY ID <br /> OWNER I.OPERATOR - f�1 <br /> 'tr _ W (/�{1 1( I /r✓/I CHECK If'BILLINGADDRESS <br /> FAclury NArart_y) <br /> tills N 1Ni1 1 oto 9522 <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zip Code <br /> y Hora or MAII INd ADDRESS (Ifllttferentfrorn SiteAddress) <br /> � -� -- <br /> b Str¢et Number Street Name <br /> 7 <br /> STATE ZIP <br /> 'taw HONE Ikt -Exr' APN# - LAND USE APPLICATION$: <br /> 11211.2 <br /> EI(T BOS DISTRICT LOCATION CODE <br /> q- ONE#2 <br /> CONTRACTOR/ SERVI E REQUEStOR <br /> ` ErO.UES.h'OR <br /> CHECK If BILLINGADDRESS <br /> L`y. c 1� PHONE Q,/,, (�'7 Err. <br /> 'BU MLS:;NIAME --- <br /> �\ 0 ��W V� <br /> f ;H6R9t or Pr'IalLlrl(,ADU12ESS. .2-5 n C0\.LjW <br /> �sCINC-{-/�/11[1�w". STATE zip �. <br /> JNC,_,hgCNOWLTDGEME,tT: },:the un der sign ed property or busigess owner, o gator or authorized agent of same, <br /> a",Lnowledgc that all site and/or o ect specific TNvutOrr�vtE AL$EALTII[DEPARTMENT h 1}?charges associated with th s project of <br /> PFJ p,. ., . <br /> activity will be billed.to me or my:.business.as.identified..on-this.£orm. - - - - - - <br /> sq eett fy that I have prepared.this application and that the work to be perfgrme 1 be done in accordance with all SAN JOAQp N <br /> �+ ,!( Tmft�,tged:nanee Codes Standards STATE aadFEDFW.Iaws. <br /> `A7rPLIGAN'> 5 SIGNATURE: DATE:y <br /> ,� c PROPERTY%'$USINHSS OWNER❑ OPERATOR/MANAGER- O AUTHORiZEn AGENT <br /> SfAPPLrCAAT.isnottheBILLiIVGPAR proof ofaatho ' ati ntd rignJsrequired C zine <br /> AIITIIORI7ATION TORELEASFJIlVTQ1fMAfIC1N:"When a alil ,xilie owner or operator o£#heptoperty located at the <br /> - - <br /> -above-slte::mess, hereby aut�onze the release of,any and zesu�lts geotec <br /> data �n or epviroamentallsrte assessment <br /> - :in#'ormahDYff�ia'(li'e'Snrr;JonQIIt[d-Go[7rrt'Y h�VyniONMENTAI. TH DBRA[T as <br /> onasit is available andat the same time it is -_ <br /> as ygy_ <br /> yACCEP FD BY: TEmp;LoYl 1'#: DATE: <br /> " (. ... ,. -,...SSI('NED TO: EYP: - <br /> Date Service Completed (If ahead,y. Dm Ieted : SERVICE CODE: PIE:. <br /> Lat <br /> rFeDP.mou`nt; <br /> Amount Paid <br /> Raytnenfpate <br /> i f'ayme lit Type Invoice{- Check,,* Rere'vadBy: <br /> 2 , 41 4 <br /> " � \r 0y r r ' <br />