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12/16/2004 16:18 12093651543 TANKNOLOGY <br />�nlv ^4 J.N UOUNTY ENVIRtONMENTAL HE As DEPARTMENT <br />ENT <br />SERVICE RFrill mvpr <br />PAGE 04 <br />�Ft'E41UeSTOR a v1N A K-t%A I UK/ SL KV ICE RE#QUESTOR <br />AuSINESS NAME. <br />PHONE i1: <br />CHECK if BILLrrt- c ADO�Ess L,•I <br />HOME or MAlumr- ADDRESS <br />FAX 11 <br />CITY t n) 5 / <br />L--- i STATE CA ZIP Q s Z <br />BILL]N 5. AC 'NOWLEDGEMENT- I, the undersigned property or businesS ownca•, operator or authorized agent of sarrtc, <br />acknowledge that all site land/or project spcciliC ENVIRONMENTAL IgCAL11.1 DEPARTMENT hourly charges ass()crued with this pr,j ,ct <br />or activity will he billed to me or my business as idcnlilicd on this lbmt. <br />I also ecnify that 1 have prepared this applicution and that tine work to be perlbrmed will be done in accordance wills all SAM Jtnnqulm <br />C:OUNTY 01-diuMIC12 Coc%s, SlvalrJar•dr, S'rATr; d FGUtsRgL laws. <br />API"LICA,NT'S SIGNATURE: T7l'"t-fCr <br />PROPt_lt'rV ! BUSIIVr$S OWNER❑ UPt•:RA'1'0k / 141ANAGt;R t.._I . <br />V7'Im,tt Au'nto1217. m Acr wr ❑ <br />N7' i,> >tn! llac B!r ,vr, A 1r77• pruojOf artiltorizafiefr to .vr'gn i.v rcrluired r;ri,r <br />r\U1'1�ORIZA'tlpN 'I O Dr. LGA3Lr INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site Address, 11creby authorize the release of any and all results, geotechnical data and/or cnvirunmer+lal/Site assessment <br />inJonnalion to the SAN .IOAQI)IN CQUN'rY ENVIRONMENTAL 1.1EA1.3'If DrPART'MEN'I' aS suun RS it IS iivailAbIc and at the Game time it it: <br />pruvided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />ACCEPTED BY: <br />A.9stGNF0 To. <br />Date Service Cornpleted (if already completed): <br />11 Fee Amount: i-7 � � Amoun# Paid <br />Payment Type ✓ Invoice 9 <br />EW) 48-02-02.5 <br />I;E\rIS[D 11 /1712003 <br />SMPtorEE #: 01 DATE; <br />EMPLOYEE #: U DATE: <br />SERVICE CODE: 1 <br />'JZQ L payment nate <br />Check 9 5R l Re <br />PrE: O <br />ved By: /J <br />SR FORM (1301deh Rnd) <br />