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���.,, ,ai>,.rt:h:-;;,�•�'.7'-,•��� ?t a�'�.�"•�.�1[l!�►: :i�l:�-:•;. Q�T��7t:9��f t' �'�1Ci�DT�tIVl;1�,N•P��r�`Ih�.r�:t�.;R-t��,��+`�:�'���'d`E �tf,;t`;.. ,����,:•.:3cr�'s(:�,�'�R.2s��cs <br /> SERNWE RE'QUEST <br /> 'fvp6 of Dulness or Property FACILITY Iii 9, SERVICE REQUEST# <br /> OWNER/OPERATOtt � <br /> ,,,, CHECfCIfBILLIHG�I6DRE55� <br /> FAC0.ITY NAME rf� <br /> SIiTT+E/ADDRESS <br /> -TAP- J P AI 3 �H�4er Ir t S(r a Gf CoAa <br /> HOME or MAILING ADDRESS {(f Different from Site Addross} <br /> Strcct Nvmbar Street plam _ <br /> Cn-y STATE ZIP r <br /> ruolleNi <br /> Exr, AP N 8 Lento VSE APPLICATION# <br /> P1fONE 2 E r• 1305 DISTRICT LQGAnou CODE <br /> { ) <br /> CONTRACTOR SE RVICE RE'Q V E►7TOR <br /> c <br /> REQUES70R I <br /> BUSINESS NANiE Pft6ftE# / <br /> HOME Or lVlA1LMC14DDRE$S l� , /�� FAX# } <br /> CITY / V STATE zip f ►���/�� <br /> D11LING ACMgyYLED(,,',VM. X, the uadorslgncd property or business ovfnor, operator or authoriZcd *gnat of sanlc; <br /> uclmowlcdge that all site and/or project specific ENVrnQN1A9NTALHl3ALTH DEPARnmwr hourly chargos associated with,this project or <br /> ntivity xvilf be billed to me or my business ss identified on this form. <br /> I also-,Cr*that 1 have prepared this application and that the work to b6 performcd will bo Bono iri aoCordanCo wide all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,.Sfaadartfs,STATB and V im•RAL,laws. <br /> "F ICANTIS SEGNAT[JJ[fE: r GIr`f DATE-: 9 <br /> U 1� <br /> vitOPE11TV/$Us(NE.sS0%vNhkt1 OPERATOR I hLkuAava ❑ OTijERAUFItomzEDAmITU <br /> If AFpld ANT is not the BIL rH47 P,(R proof of whoriiation to sign U required T1 rt e <br /> UTFiQItI TION'FO M,ROE WFORMAnON: When applicable,l;tho owner or operator of the property locatad at(lie <br /> abovo site address, hereby authorize the iclease of any and all iesulls, geotechnical data and/or environmentalh0te assossnicnt <br /> information to the SAN JOAQUIN COUNT-Y ErivutpNM13rUALHsALTH.DEPARTMPNT as so-on as it is av3llable And at the sauce time it is <br /> proYidcd to nTc or my representative. <br /> TYPE OF SERVICE REQUESTED: Aeal1&1 cC V F-D <br /> COesMsIRS: lallft-71- yl�4� d ®A X f% G \ OCT 112004 <br /> *Atf j0A0UIN COUNTY <br /> EWIRONMEyNIALL (� <br /> /r! F��DEPfkATtAENT <br /> `/�J <br /> 1 <br /> ACCEPTED BY: 1_MPLOyreft 49,00-11 <br /> ASSIONEDTO: L•MPLOYEE#: � PATE: <br /> Uate S©tvice Completed (If already completed): SCRVocE CODs; PIE: <br /> Foo Amount: Amount Paid "ymunt Dato <br /> Payment—typo ✓f InvoiCQ# {`ihtok# {41 R©GoiY0dL3y: .(— <br />