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Cot''rT 1,,0NNfrNTAL liFAur i1. DP.PAI"I <br /> S v jo.A6Qr < <br /> SERVICE REQUEST SERVICE REQUEST# <br /> FACILITY ID# <br /> ype at Business or Propedy AppRESS IJ <br /> CHECK if BILLING <br /> 0,,%NFR I OPERATOR IJ t Y-� <br /> Fu iL"N Z, Code <br /> Ci <br /> SITE DRESS street Name � `� (f <br /> r Strut Number rection Y <br /> �n str T Wattle <br /> H a•'MAILING,.013RES5, tlf t]iffnrent from Site Addrass) Street Number <br /> STATE j <br /> CITY _ 1 r� <br /> LAWS USE APPLICATION# i <br /> Ps+oh-#i Err. APN# <br /> SOS DISTRICT LOCATION CODE <br /> PHONE 92 Err <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTO <br /> CHECK if BILLING ADORES <br /> REQUESTO. 01 1 <br /> t � PHONE <br /> BUSINESS NAME <br /> FAx# <br /> l HomE or MAIL) A.TD�SS <br /> j ! v 0 Il <br /> t� STAT ZIP � <br /> CITY , ©S\ <br /> Iili.LtT'G AQcj0NVLEft FN1ElV'T: I, die undersigned property or business owner, operator or authorized agent of same., <br /> ledge that all tiitr and Ir tir.�leCt specific E- VTRnF�[ME'NTAL IIE-ALT11 DEPARTMIENT hourly Charges associaled with this prk jest <br /> or activity will he billed to me or m}-business as identified on this farm. <br /> I also certify that I have prepared this application and that the work to be perfunned will be dune in:accordance with a]I SAN JOAQUIN <br /> CoLn,-re• Ordit►atrce Codes-Standar-ds TC•,and IW5. <br /> APPLICANT <br /> ,S SIGNATURE: DAYE: <br /> I'ROPETt7V BL�C�ESS OWN I MANAGER t3 OT HEu AI-'IL110RIZ.ED AGE`r❑ <br /> If-4PF11Ca'V7 is rtor the BILIJ.`GPARL proof of aulharizafion fo sign is required Tide <br /> A rTN RIZATlON TO RELEASE INFORMATION: 'When applicable, I, the owner or operator of the property located at the <br /> aboN, %ite address, lieTeby autioriuz the reiea"'e of any and all results, geolechnical data and,,'or env ironmental,site assessttlint <br /> infonriaJon to the SAN JOAQUN Cob'-N-rY ENVIRONMENTAL HEALni DEPARTNtuNr as soon as it is available and at the. Sanle tilni it is <br /> pro,id,,d to me or my representative. <br /> TYPE OF SERYCE RE VESTED: <br /> CCrAAEtiTS: <br /> `^ r <br /> AccEPTED BY: Ty <br /> EMPLOYEE#: <br /> DATE: V �5 .rZ�.- r <br /> A551GhE7 TO: L , EMPLOYEE#: �✓ { <br /> Date Service Completed (if already completed): ` DATE: <br /> S�RVICI CODE: U <br /> Fee Amount: , � �-- Am <br /> ount Pal[t_ <br /> ayment Date <br /> Rn <br /> Payment Type invoice# <br /> Check# _ <br /> 5 "A Received By: j <br /> RMS4&024)25� 1,32-T.37/,�, 3R Fr-)Rkj <br />