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Nov 26 14 02146p E l i t Iv Contractors Inc 2994612 <br />SAN JO AQUIN COYTr n ENVIRONfYIT+,NTA!`J UMALTH MPARTNIFNT <br />SERVICE REQUEST <br />P.3 <br />Type Of Business or Propcety <br />FACILITY ICI # SERVICE REouEST # <br />3835 S&oo <br />OWNCR I OPERATOR <br />4 <br />CHECK If BILLING Ai__ ORk55 <br />13J <br />FAciurr NAME <br />1. r , <br />SrMADDRESS <br />[ <br />I)C-' <br />' <br />C' • r <br />ember <br />Dim .flMl <br />Siena Nama <br />C1 <br />Z Codo <br />HOME Or MAILING ADDRESS (ii Uiffemnt from Site AddmsS) <br />A$front <br />N. <br />Number <br />'Saraaf Nn ma <br />CeiTY <br />STATE XIP <br />PHON01 Ear, APN # <br />LAND USE APPLIC MN # <br />PHONE til Ezr. <br />SOS rNMICT LOCATION CODE <br />CONTRACTOR / SERVICE RE(, U ESTOR <br />REQUESTOR <br />GumNESs NAmF, / <br />ITOMF Or MAILING ADDRess <br />CITY <br />CHECK if BILLING ADDRF_SS® <br />PH NFA . }. y C <br />Ml - <br />vv [ � � ) /fit' y STATE 7JP <br />UILIULeny AJU10 )M1 liG W_.NT: 1. the undersigned property or business owsaer, operator or autborirced agent of same, <br />acknowledge that all site and/or project specific ENviRpNMi:N'rAT. 1-THAr„.rti DuARTm ?NT hourly charges alasoclated with this project <br />or activity will be billed to me or my bugrsess as identified on this form, <br />I also certify that I have prepared this application and that the work to bo performed will be done in accordance with all SAN JOAQUIN <br />COUNTY On finance Coder, Siandc rds, STATr; and FEDF-RAL IIWS, <br />APPLICANT'S SIGNATUM.: DATE! <br />PaOPMTYI''lio4iripm OWNIC14 0 0PXkKrole/MANAexu © OTerkfeAvmoRtzi;DActrwr }0 a, <br />... ... IfA.PPQ?UtYr..is.not rbe_13rr.(.rtyU PARI Y, proof ojarrtlinrizaliun 10-11911 4x required l T1rte <br />—RUTH i TI N T ASE TNEQRWLT10: Wben applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or erivironmentillsite assessment <br />information to the SAN JoAQUIN COUNI"Y ENVMONMLNTAL HEALTH DEPARTMENT as Saoli as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SEWCE REQtJ ESTED:WILY L 1, �� <br />CDfdNIGNts: DP , <br />_O <br />' Af y <br />AccEPTE'D SY: <br />Ass{riiEaft <br />: <br />Rate Servieo Completed (1f alroaady comptetad): <br />Fee Amount: Amount <br />Payment Type invoice <br />Ri-VISED 11/1712003 <br />EMPI.OYEE #: <br />:EMPLOYEE #- ! Z <br />DATE, <br />DAYS: 2 Z 1 <br />PIE -2 3pg <br />N L)V 2 eR (Golden Roll <br />ENVIROWEN AL HEALTH <br />OEPARTMENT <br />C <br />