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Work'Order: 2255439 <br /> SAN JOAQUII I COUNTY I.,NVIRONIVIFINTAL HEALTH DFPAR-I'MFNT <br /> SERVICE REQUEST <br /> 4 <br /> Type of Business of Property FACUTY 10 <br /> 77 <br /> OWNER I OPERATOR CHECKIf Al—l-LING i—:.- <br /> --jL <br /> FAZILI:"NAME <br /> HOME or MAWwa ADDRESS III Different fro rr Site Addres-ssl <br /> CITY STATE ZIP <br /> p ',I E, APN# LANo use AN-LICATION 4 <br /> F•tori E."•2 BOIS DISTRICT LXA-nc <br /> CO. TRACTOR I SERVICE REQUESTOR <br /> RrOIJESTOR CHr(.'X it 13ILLI NrJ <br /> BUSINESS 14AME PHOKS 4 <br /> koty I= S <br /> or MAILINGADDRESS FAX <br /> CITY STATS. zip It <br /> jjjLtjNf. ACKNOWLVA)GEMENT L,the undersigned properly or business owner,operator or.4ulil(WHZed <br /> az;knowledge that all silo andior projDC <br /> or activity will be hillcd to me or my higinmus identified on this form. <br /> I also certify that I have prepared LhiAa plication and thm the work to be PCTiorined will be done in accordance with-,III <br /> I Y 0i-dinaiwe f4wes.SkIfidar(Is 4� n,and Fi;j)IiRAI.Jaws.,%PPLICANT'S Sj(;NATURU: 4 DA TV:� <br /> -YRvtoK F.K 11 Gr <br /> Nrequired YRJr <br /> ,%jJ'1-IiORIZAT1ON'j'O KELEASF INFORMATION:When applictibte,9•the owner or operator ofthc pri)ptrt% <br /> at,()vv. site 1(ldre..", hereby 'L1UthUTiAI! 1%6 IrCIC1.15C or any and all results, geotechnical data and.'01' environmental <br /> infurrmilion Lo the StNJOAQ(11*4 COIN'Y I--,N N <br /> .rrovided to me or my representative, <br /> TYPE UFS;RIVJCE ReQuFsrm <br /> ACCEPTED-By, EMPLOYEE#: DATC <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service ComplebLd (if already toj ripirted); E�110E CII.E. P)E; <br /> Fee Amotini- Amount Paid Payment Date <br /> Payment Type Invol I?# -FCh---k V Received By <br /> EI ID 48 02.IJ25 SIR FO <br /> REVISED 1111712003 <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />