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SAN JOAQUIN COUNTY ENVTROKMF.N'TA1. HEALTR I FIRARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILRYID# SERVIC€REQUEST it <br /> OWNER IOPERA TOR I !- <br /> Crters IfBe,iu AcxmxssLl <br /> FAM"NAME <br /> Sq AOM F did AJ VV,7c <br /> m <br /> How ofllkAlINGASORM (If Different fmmSiteAddress) <br /> nr <br /> I <br /> CITY .STATE Zh. <br /> }MORES4 o'T• APNI UNo Ust AoPLICATsCaR <br /> 1'HtidE ! tis. SOS DISTAICT LOOATOM Come <br /> f 1 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REauEsrm <br /> CFiFdrif EiILLINQ ADGEES30 <br /> HUW489s NME 1EQ a eav <br /> HOME or MtdLmoo ADD _ r I .. ,f FAC# <br /> �f dADt, f 1 <br /> Cnry STATE ar <br /> BILLING ACKNOWLEDGEME\T. L the tmdemigried property or bvsineas uwww, operator or aathorizej agent of same, <br /> acknowledge dist all site an&Dr pro*t specific ENvototvi u,N-ral.Hr•ALTII I)EPARTNiF.NT hourly charges.associated with This pmjecl <br /> or activity will be billed to me or my hwAitess as ideelified on chis form. <br /> I also ecrtif r that I have prepared this application and that the work to be performed will 6e done in acaordm=with all SAN kmfjuIN <br /> Ci)Lany Ordiname(:odEP,Srdnd * 4TATF and FMAI.IrML J <br /> APPLICANT'S SIGNATURE; �l J IyArt: 7f I e-7- �20- <br /> i <br /> PFA)Pmrt•r 8tlatxm Ch%,NTA 17 QPr.R.iT(]R l MANAMM EY CMIEIt A17ruOR77.EDACE\T13 <br /> YAPi-u-4.NT is not fhc,91&U.%7j P-4 1',Proof of aurhoriwion to slgu is rcgvireat rare, <br /> AUTHORIZATION TO RELEASE INFORMATION: Mhen.applicable, I,tate owner or operator or the property located at the <br /> above site- address. hereby authorize the Tebmse of any aril all rosudts, gec4echltica1 data andror envimnmcntallsite assessment <br /> information to the SAN k,L.OMN GOI.'NrF "NFIRONNE.KfAL FIEAL.111 DEPARThfENr as soon w it is available and of the-,Inlc time it is <br /> provided to me or my Tepmmrastive, PA <br /> TPE OF SERVICE FIEGUESTEn: <br /> COMNEM.- D <br /> DEC 03 ?p?0 <br /> S jo <br /> tv AQU/lye <br /> NEgi Ty�F ART 4E <br /> AcCEFtEoB - ct-v ! Alf c- a Eu[ toYfEO, ELITE: Z L -2-0 <br /> As=NED TO: L,k �G,�.Q._y Eu-LDYEE O: DATE: <br /> Uattr Setvlee Completed of afmady m=ptrtvdl= SERVICECAOE:. <br /> Fee AmotrnkAmOLRIt P ��2 ,U� Payment t7ate �J 3? <br /> PaymerttTyps Invoice it Check 91 Receiv By; <br /> EMD 48-02-025 Q� -, i _ SR FORM fGclten Redj <br /> REMEDT11IM003 <br />