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NOV 2.1 2000 3: 25PM HP LRSER3ET 3200 P, 3 <br /> SAN JOAQUIN CorjwY rNVIRONNirNT'AL HEAT,W DF:1tAltI'MEN71- <br /> SCRVICE REQUEST <br /> Type o!Business or Property FACILITY 10 R SERVICE REQUEST A j <br /> r PRA - <br /> �t® CHECK if SILUNC AOORESS <br /> Atd <br /> TY cit-, I <br /> SITE AOoRE55 <br /> y Street NumAcr cIt t t N G Ii i Cods <br /> HOME or MAILWG ADDRESS (if aitferent from Site Address) <br /> 31ree umber Ir N <br /> Carr STATE 21P <br /> i <br /> NONE 91 EST. APN 9WtD USE APPLICAVON tY <br /> i D <br /> PrONE92 EST. •60$DISTRICT <br /> LOCATION COOS <br /> 1 I <br /> CONTRACTOR/SERVICE IMI QURSTOR <br /> REQUESTOR <br /> CHECK If BILL INC A00R E S 5 <br /> EUSINESS NAME priOyE Ecr. <br /> 3 <br /> HOME or MAn wo ADDRE S FAX 0 <br /> D ) 3 <br /> CITY <br /> STAT" <br /> BILLING ACKNQWLFDCFMEN'r: I, the undersigned propei-ty or business owner, operator or authorized agent or samC, <br /> acknowledge that all site and/or project specific L-NNVIRONMIiNPAI-litPALTti DOARTMENT hourly elurges associated with this project or <br /> «ctivlty will be billed to nic or my business as identified on this form. <br /> 1 also ccrtiry that I have prepared this application and deal the work to be perforated will be done in accordance with all SAN JOAd)UIn, <br /> COUNTY Ordinance Coder,Star►durdv,STA'rr and 171211113RAI.laws. <br /> �t�--•APPLICANT'S SICNATUREj <br /> / _ DATE: <br /> PKOPFAT-Y/AtisiNvis 01YNcn13 OPERATORI MANACF,II ® OrNERAUT11Oftmru AcrNT D <br /> /j/IYNI.IC�NT Is not dee D1Glitysr& /�ranjvjvrrtlroriurliare to sign ea rcgretred TWO <br /> AUTIIORI?ATI N TO RFT,EASY 1NF9RMAT,f,�N; When applicable, t,tilt owner or operator of the property located at tete <br /> above site address, hereby authorize the release or any and all restdts, geotechnical data aridior environmaital/site assessment <br /> inrornta:iOh to the SAN JOAQUIN COUNTY ENVIRONMM. TALHt_ACrH DEPARTMENT as soon as it is available anda <br /> provided to n1(Dt<c sa,n1E lime it is <br /> x�or my representative, r;l MG1`t <br /> TYPE Of SERVICE REQUEsno: ,T-- <br /> COMMENTS: <br /> NpV 2 $ <br /> sAN <br /> ,loAou,N cov►� I <br /> �N oEPF-%'f 1tsr I <br /> APPROVED BY: EMPLOYEE fit: t <br /> RATE: h�-- <br /> ASSIGNEO TO: EMPLOYEE 0; "°C• <br /> Date Service Compictad (U already comp4oted): � � <br /> StiRWCFCOt7E: P/E:G.3b i <br /> Fee Amount: IVU Amount Paid r� Q v� Payment Dato J( <br /> Payment Type Invoice a "Check[tt S� <br /> (�0j'] Received By: <br /> EHO 48-01.025 <br /> R!�VISEO 6.5.02 SERVICE REQUEST FORM <br /> 2 •d fr1bL4E660Z gaatj UOIAO04S J0 rll4?a eS0 :80 SO ea ^oN <br />