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SAN JOAQU1N CbUN'I'Y ENVIRONMEN'1'A1, #1EAI,'1'll DEI'AR'I'MrN'I' <br /> SEHIVW6Ti', I( EQ UEST <br /> Type of Business or Property FACILITY ID 11 SERVICE REQUEST ff r) <br /> OWNER/OPERATOR l CHECK If BILLING ADDRESS11 <br /> FACILITY NAh1E <br /> SITE ADDRESS �, f� �.� <br /> - M c,ct,I-e C.'ct. <br /> Shoot Numbor Dlrocllnn Strnnl Nano, Cil 71 Cnrin _ <br /> HOhIE or MAILING ADDRESS (If Different from Site Address) <br /> Sfranl Numbor Slront Nano <br /> CITY STATE ZIP <br /> Pliou tti Exr" APN it LAND USE APPLICATION It <br /> PHONE 02 Exr. DOS DISTRICT ��LOCATION CODE <br /> REQUESTOR <br /> — J CIIEL'I(If BILLING ADDRESS = <br /> BUSINESS NAME _ <br /> PHONE it ExT. <br /> r;v C. C fit?.I r c t'c' ► ,n Y i ( <br /> 1'I0L1E Or MAILING/ADDRESS FAX It <br /> CITY STATE LIP <br /> BILLING ACICNOV✓L{sUGEMEN"I': 1, the unclersigned property or business owner, operllor or authorized agent of score, <br /> acknowledge that all site 111(1/01'project Specifie FNVNt0NrvlliN7*Al.l lHAI:rLI DEPAR•fMIXF hourly charges associalcd with this project <br /> or activity will he billed to me or my business as identified on this 1i1-111. <br /> l also certify that I have prepared this application and that the work to he performed will be clone in accordance with nil SAN JOAQUIN <br /> COIJIN I Y Ordinance Codes,,Slundurdr,S'i'A'Ili and I:UI:RAI.laws. <br /> APPLICAN'll"S SICNA'I'URE: , ��� <br /> PROPER]V/DUSINESSOWNER[] OPERATOR/AIANAGl:It ❑ Orrn•:ItADrNORIzeDAGENI' <br /> If1IPPL1(,'Avi is nu/the 81/.!./,V(J PARTY,Praoy-nf wilhorizaliun la sign is required Tir/e <br /> AU'L110R1Zik'H0N TO RELE\SL: INFORMA'HON: \VhciT applicable, 1, the oTvner 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 environnlen(al/site assessment <br /> infol'nlation to (he SAN JOAQUIN COON I N' IiNVIRONMENTAL I II:AI:I'U DFPAI0AIG14'I'as soon aS it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> C., j <br /> r(�inl <br /> f. , <br /> COMMENTS: RECEIVED <br /> (/��( <br /> KI <br /> _ r— <br /> \N JOAQUIN COUNTY err' A O <br /> ENVIRONMENTAL <br /> '"-"I T)IDFPAFI'1MENI* <br /> ACCEPTED BY: l In /� EMPLOYEE tt: C(.ir'(; C ) DATE: <br /> ( <br /> ASSIGNED TO: - / a� I /�'��:� � EMPLOYEE IA: ` "�'�, DATE: <br /> Date Sorvico Completed (If alroady complotod): SERVICE CODE: n P!E: <br /> Fee Amount: ( , L Amount Paid 5.6 r Payment Date IC9 I <br /> Payment Type L`(_ Invoice It Check# G Received By: <br /> Ef ID 40-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />