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y%hf�F4 — <br />6ERViCE REQUEST W- UH DO 61) Revised 8/23/93 <br />FACILITY 10 # . REGGRD ID INVP.ICE # <br />FACILITY NAME PILLING PARTY Y / N <br />SITE ADDRESS <br />CITY ACA ZIP <br />OWNER/OPERATOR FBILLING PARTY Y / N <br />- i <br />DBA I` - �A (� C a rnif\ PHONE #1 ( p2_ <br />ADDRESS � � C K�A-'f\P06" LXI PHONE #2 ( ) <br />CITY 1� ,+ STATE Ck ZIP <br />APN# Land Use Application # <br />r SOS Dist Location Code \\ <br />CONTRACTOR and/or � � <br />SERVICE REOUESTOR W`M%eC1 I IIQ f �^�— Y�LI BILLING PARTY N <br />DBA J P N A I(�'� S CJ�� I � IVDP PHONE #1 ( -Q0) �L <br />MAILING ADDRESS i� 1 (1��FAX # (� )Q�=C9/0 <br />CITY IA � (P STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of smmw, acknowledge that ill sjW'j <br />ject specific <br />PNS/EHD hourly charges associated with this facility or activity Will be {filled to the party identifkING PARTY on <br />Page 1 of this form. �� <br />MAR 1 71��� <br />I also certify that I have prepared this application and that the Work t..4 In performed will to dim in acCOrdNbi�+ith all SAN <br />JOAOUIN COUNTY Ordinance Codes t da, 504 and Federal Law-Pual SAr4 'C'�QutN <br />�NVIRONMEN ALLNse��L'IR <br />APPLICANT'S SIGNATURE <br />v �( <br />Title • ;,* _ ._,_. _ 9.40 a �~ [ � " <br />AUTHORIZATION TO RELEASE INFORMTI(itl: Irl addition to the aWyv-, Wtkw appli&ablef I, the owner, aweretor or agent Of same, of <br />the property located at the above site address har4y autharite the release of any and all results, geotechnical data and/or <br />environmental/site assessment infgreaetign CQ SAN JQAGUIH GOUNTY PUDIC "TH GIRVICE6 6NVIRO"ITAL UALTH DIVIIIIDY as soon as <br />It Is available and at the same tim it is provided to me ar W representative. <br />Nature of service Requests �' v 'SGT service Code L <br />Assigned to l . T���, UP.Loyes : 0 (Colo Date <br />Date Service Completed // Further Action Required: Y / N PR4IitIW ELEMENT < <' <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Paywt Type Receipt # <br />ow -k # <br />Recvd NY <br />REHS I/__/_. I SUPV I _J_J I AGGT I .._�,—J I UNIT <br />