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Nov 20 14 02t02p Eli Iv Contractors Inc 209461 42 RECENEQ <br /> NOV 2 0 2014 <br /> SANv JOAQUM COUNTY EWMONMENTAL HEALTH 1)Tc.PA"9T1—W1 RUN MENTAL HEALTH <br /> SERVICE REQUEST DEPARTMENT <br /> Type 4f Business or Property FACILITY ID# SERVICE REQUEST# <br /> - C i, 3 S�� 57/0 3S <br /> 6M6R i OPERATOR <br /> CNWK if E11LuuG AnDKFss 0 <br /> FAGurY NAME I <br /> 1 fm <br /> SIrEADDRESS 1 i(.�°��� <br /> t eudn <br /> HOME Or MAILING ADDRESS (if Different troth Site Address) <br /> Y\ A %tryst Number f Na <br /> CITY STATt: zip <br /> PHONE 41 fir• APNax LANDUsEAPPLICAPONrt <br /> ( } <br /> RioNEW2 Fxr' 00S DISTRICT LOCATttSN LODE <br /> t r <br /> CO N TRAC'fOR/SERVICE REQUESTOR <br /> t71itlUE370R <br /> 4 C*CK If DILLfri r AC cem <br /> suslNr:ss NAM1+ -- t .�� ,�, P,�pt1F <br /> � <br /> HOME or MAILING AvnRFssy FAX# <br /> STATEen Trip 1.2c <br /> . <br /> RILl iNC AQCN WI KDGEMEN'P I, Bre undersigned property or business owner, operator or sautbori*.td agent of some, <br /> acknowledge that all site and/or project Specific J;'NV1R0NM19`rrAL HEALTH DEPARIWNT hourly cbarges associated with this projrzi <br /> or activity will bc'billed to me or my'business as identifier(on this fonrL <br /> I also certify that I have prepared this application and that the work to be performed will be clone in accordance with all SAN JOAQUIN <br /> COMY Orf/trance Codes,Slandardc,STATL,and FLDFRAZ,laws, } <br /> MMUC M'S SICNA7'(,T1tX+;: < - lJl , 4 i DATF,: l 4 2(1; � <br /> T'rtoTEIt7 S I Timms O"Ica O 0P%RAWR I MAtfiiC a't❑ 0'17►rR AuTnotttratu AoENT Q ( J.{ 'r Ic,1 i 1{l <br /> f APPF.1r,,4 'is not Ike llJ lNl,'PAlt7Y./�rnuf ajautfire#zrttiore to sign Isrequired Title <br /> A(jXQg7 T&&TW TO KINIL.IEASE iNFO1tt1Ma(ON: When applicable,1,the owner or operator of the property located at the <br /> above site address, hcreby authorize the release of any and all results, geotechnical data and/or enviroamentallsite assessment <br /> information to the SAN JUAQ um1 COUNTY ENvIRQwwlAL L'rf[DFPARTMt1ir4-1-as soon as it is available and at the same time it is <br /> provided to me or my represcntative. <br /> TYPE OF SERv10E REQUESTED: :l�l' Il1i V{ t i_:'ti�:. (IC'ir't°1� 1 Cif 1 Di c`.-,� '�>1. j f �'i.'•6ti1 ` F SME <br /> fiOMMENfS: 1���.tt�t:C'1 �t.t�'2�.� i'rn1Y�c�'�icwt�.>L ; c�� EJiC::�r:.� I`�1:;��k't1�'�'•• ErVET <br /> Nov ° <br /> S � l <br /> H�irti ti��� <br /> E nl� <br /> ACCEpub BY: EUPLOY4Q <br /> Assi"e't1 To: <br /> .- EMPLOYEE#: RATE: <br /> fate Service Complet*2 ttltr dy completed}: SERMECooE ,6,8 PIE: Z3 Q <br /> Fee Amount a''e' Amount Pat !0 O� payment Dat© <br /> Payment7Ype fs Invoice Ch 7IaZ-76 ReceivodB . <br /> "' '• "EHD A$-o2=025 - <br /> R12-VtS5011/17120os Sri FORM Goldie Rod) <br /> • <br />