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Nov 21 14 02:38p Elite Iv Contractors Inc 20946 142 <br />SAN JOAQUIN COUNTY ENMONMENTAL 111EALT11 DEPARTMENT <br />SERVICE RJEOUFST <br />p.3 <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESMIZY bJr ) I r <br />SERVICE REQUEST# <br />CHEM It BILLING ADDRESS© <br />.'OWMM OPBRATOR <br />CHECK MLUNGADDR��o <br />PMM# <br />ExT. <br />SIM mms. - J-5 <br />_�tServlceCompklad (ifalmadycomptow)_. <br />I I <br />�0 <br />HOME or MAJUNa ADDRESS - C- <br />VY <br />AmountSERYMM <br />FAX#. <br />tAl � i <br />54"t Na.t. <br />CITY <br />cow7.1 <br />STATE <br />HOME Or MAIEJNG Alit RPM' Different from Sko Addroes) <br />by.v <br />V11 <br />AZL <br />CirIY <br />STATE zip <br />PHONE, #1 <br />APH S <br />LAND USE Appur-ATm 9 <br />PHOW92 <br />DOS Di-,MICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESMIZY bJr ) I r <br />CHEM It BILLING ADDRESS© <br />BUSINESS NAME c(de-"5L <br />DATE. <br />PMM# <br />ExT. <br />DATE. <br />_�tServlceCompklad (ifalmadycomptow)_. <br />I I <br />�0 <br />HOME or MAJUNa ADDRESS - C- <br />VY <br />AmountSERYMM <br />FAX#. <br />tAl � i <br />it I - ((3 1-2- <br />CITY <br />STATE <br />ZIP <br />'RrL1,FNG_ACIKN0WLFJW.EAfE?M, 1, the undersigned property or business owner, operator or authorized agent of same, <br />-whowl <br />edge that all site specific ENVIRONMENTAL HLA.LTH DFYARTmr�n' hourly charges associated with this project <br />or activity will bc'biBcd Wiui-0 my*ba$iaas as identified on this form <br />+ also oeA4 that I have prepared this application and that the work to be performed will be done in accordance with all SAN J OAQTJIN <br />COUNTY Ordinance Codes, Siandmn*, STATE and FmcRAL laws. <br />"IrUCANT'S SIGNATURE: )DA= <br />PRorxaTy / Bu.-wNF-m 0wNxR0 Or=ATm/MAmcxn 0 OST; x%z AuTuoRww AoWT4 0 <br />fi <br />TO REBASE REM&IM When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release ol'any and all results, geotechnical data and/or envirommental/site assessment <br />in.faftnation to the SANJOAQUrN COUNW ENVIRONMENTAL HW.TH DEPARTMEr4T as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE R Lx' u'� <br />LmmoyErM <br />DATE. <br />77As�si1N1WT6"::ItMPL <br />OYES #: <br />DATE. <br />_�tServlceCompklad (ifalmadycomptow)_. <br />CON: <br />1P I F_ <br />/Fee AmounAmountlaid <br />AmountSERYMM <br />Pay <br />Invoice # <br />Check # <br />by.v <br />Payment Type <br />_ERUW02-02'5"—­__­ - <br />FtEIOSED 1111700 <br />N 0 V P10"WoNift <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />