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-se, t,,--- DD &I <br />FACnmN&WE Levand-Bright Property <br />SITE ADDRESS <br />TYPE Of SERVICE REQUESTED: <br />3 East Eleventh Street <br />I <br />Tracy <br />95376 <br />sh-1 N—k— nlror•+on 54-1 M'M� <br />C. • <br />71 r -'.n <br />HOME or MAILING ADDRESS (If Different from Site Address) 24692 <br />Sand VVedae Lane <br />SAN JOAQ <br />CITY <br />STATE Z1P <br />Valencia <br />CA <br />91355 <br />PHONE 91 [" I AP N O <br />i <br />LARD USE APPLICATION Yr <br />(1361))9&1-2133 233-3613-16 <br />DATE: Z LI 1 "t- 1 <br />ASSIGNED TO: <br />PI<1HE X2 E T- <br />BIOS D15TR►c7 <br />LocATi,," COD=_ <br />Date Service Completed (N 11roady canpleted): <br />SEF'A[ECOCE:O 9 <br />Ple Z?,, p (- <br />Fee Amount_ <br />CONTRACTOR / SERVICE REQUESTUR <br />RE.QUE:STOR <br />Robert ?.tarty CHECK lfelulNDAnnvcSs <br />BU -,NESS NAME PliciA0 [" <br />Advanced GecEnvironmenlal, Inc. 209 467-1006 <br />HOME or hMt-r.vC ADDRESS 837 Shaw Road Fmv <br />( 209 ) 467 -1118 <br />CITY Stockton STATE CA Zip 95215 <br />IIII.I.ING ACKNOVI'I.EDGEAIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site :utd+or project specific E%XIRr1ti\II:%'T.aL HEALTH Dr_PARTMENT hourly chafes•, associated with Iltis project <br />or activity will be billed to me or my business as id,:ntiticd on this form. <br />I also ec►tify that l have prepared this application and that the work to be perfbirnod will be done in accordance with all SAN Ir>,vr�U1N <br />Cul'V71'Unlinwre•rCuelev.StuurlunLv.S �1tandFGUI:R.tllaw3`__ / I <br />APPLICANT'S SIGNATUIR D.>,rE: / <br />PnurinTYiDcsL�t�sOa�tl►(� OItxl7Ultr�Lu.u:rat❑ On►r:xAnuux►zeDA►:Evr❑ <br />1T.1PPttcrvT is nor rhe 81LL1.\'O F'. Ler;. proojr+jduthori.-adon to sign is rrynired rine <br />AUTHORIZATION TO RELEASE INFORNIATION: When applicable, 1, the owner or operator of the property lucaicd at the <br />above site address. hereby authorize the release of any and all results, Scoicchnlcal data and,ur cjtOronnwntalraitc US e.i►nent <br />inforn ation to the SAN 1DAQUIN COUNTY E,.viK s'NIL•'NTAL HEALTH DEPARTNIE•NT as suun as it is available and at the sante tir►tc it is <br />provided to Inc or my Iepresentatisc. DAW <br />l � <br />CAPQo�q I o� <br />ENT <br />LVED <br />Y 2014 <br />IN COUNTY <br />ENTAL <br />ARTMENT' <br />1Cfjce' t - <br />Z 2 <br />TYPE Of SERVICE REQUESTED: <br />CONVENTS: <br />FEB <br />SAN JOAQ <br />HEALTH DO <br />ACCEPTED BY: t'� <br />EMPLOYEE: Zb O <br />DATE: Z LI 1 "t- 1 <br />ASSIGNED TO: <br />T/ �N� <br />EMPLOYEE#: <br />1 DATE: <br />Date Service Completed (N 11roady canpleted): <br />SEF'A[ECOCE:O 9 <br />Ple Z?,, p (- <br />Fee Amount_ <br />Soto Amount Pat <br />5j$�� <br />Payment DJate <br />h! <br />Payment Type <br />Invoice u <br />check # 38736 <br />1 Received By: <br />l � <br />CAPQo�q I o� <br />ENT <br />LVED <br />Y 2014 <br />IN COUNTY <br />ENTAL <br />ARTMENT' <br />1Cfjce' t - <br />Z 2 <br />