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Nov 21 14 02:42p Elite Iv Contractors Inc 20946 142 p,2 <br />SAN 1OAQUW COUNTY ENVMONMENTAL REALLTa DEPARTmrNT <br />SERVICE REQUEST <br />yp o usmcss ar, <br />FACIUTY.10 # <br />SERVICE REQUEST # <br />0wNrR 10PEPATCN2 <br />-FAcjLffy Nor- <br />5trtcADARESS � r" <br />' <br />. <br />Slrtel Mumpnr <br />nUMEilan <br />SHaot Name <br />Cala <br />NoutP orAkuNGMoms. (If Oftrentf om Sero Address) <br />Ifaal Numtur <br />trwt Nanw <br />�.. <br />t,Y <br />STATE ZIP <br />PHoW#1 ExT. <br />APIC* <br />LAND Use AwuCATTo a <br />PHONE #2 > xr. <br />BOS DISTRICT LeacATtoN CODE <br />CONTRACTOR. / SERVICE REQUESTOR <br />REQUESTOR u <br />i � E ! '; ti'1 ' crttac it el>.T.n+c-AI�DRP.Ss. <br />BtaSINm NAME PHON6 # t i �• Ex*. <br />HOME or MmuNo A DDRess . '!- . - FAX.# <br />A <br />z C, t zi <br />CITY .S`TAYE ZIP <br />BILLING ACKNOWLIBDGEMt+ [, the undersigned property or basiom owner, operator or authorized agent of same, <br />::clonowledge tharalf site and/or project specific ENVMCNMENTALHF.ALTFIDECAItTMLzNThourly charges associated with this project <br />or activity will be billed to—inc—of my business as identified oo this Corm. <br />i also •certify that I have prepared this application and thatthe work to be perfomied v411 be done: in accordmwm-with all SAN JOAQUIN <br />COUNTY OrWm=ce Codes, SAMCfards, STATs and FMp.RAL laws, <br />n <br />APiI`LiCAM'S SIGNAIV DATE:_ !- I(�i 2 <br />PRor>zrr /icewr% o=O 01� / MAK tGXR n OTmm Aornonso Aczwr <br />...---------.....1.1i1',pt/Y�yT-ls.tlofl <br />.f %�JLLaVG,P.AR7,_,Y�,hof_ofmrrliorlta/4inloadgn.iseegre�frrd........ Tule...... ..._ _... <br />When aWlicabh:, Y, the owner or operator of the property located at the <br />above site address, hereby mAbOrizc the release of any and all results, geotechnical data and/or envirodmentallsite assessment <br />infonmation.to. the. SAN JOAQUW, COUNTY-ENVIRONMEWfAL HM711 DEPARTMENT as Soon as it is available and at the Sam time it is <br />provided to me or my representative, <br />TYPE OF St7tV m Rr;quesTE . �. (.1 y,. r ! <br />Coiirnxrs: C S I M <br />F F/ FNT <br />NOP <br />19 JO08 <br />lea ti'r,� <br />EnPT..oY� DATE: <br />7 <br />:.... - -- - :AsSHiN oto: - : •. ,____ ._:-......... _..._ <br />_ _.:_.._._.... J.EMIoYI_17ArE:_.. <br />Dafm Service Comptatcd Of al6ody eomptet d):.. Sra ft CODE: �(� P 1 E: ��� <br />Fee Amount: ?�G1f�} dont f>a 3 qD. V b Payment Date <br />Payment Type ! Invoice# Gtl 7//2, <br />----.. ,.EWD Iii 82�2� _—._._ ._.......---._ .. _ ... ...._,..__... ---- , ......_......_ ...._ ...... .. . <br />REVISED 11117/2003 <br />SR FORM'(Golden } <br />NOV 21 2014 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />