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SAN JOAQUIN COUNTY E;NVIIN)NNI N'I'AL IIFALTIi UFI'ARTMFN'r <br />SERVICE REQUEST <br />Type of Burin or Pro rty FACILITY Ip i <br />SERVICE REQUEST s <br />BUSINEss NAME I <br />jam. t ,1 p <br />coewENrs:t1 'k)y75 exp(lvided. s'erilc <br />OWNER 1 OPERATORApDRE5513 <br />ACCEPTED BY: Z' <br />FActurY NAME <br />ONA <br />SITE ADDRESS ' <br />b <br />FAx0 <br />A <br />NOME or MAILElrs ADDRESS (If Different from Site Address) <br />R <br />n e Nurebrr <br />STATIF yip Oj a <br />CITY <br />STATE zip <br />Alia <br />PFrOME Rl EXT. APN t <br />t �' x-14 ►�'"' � �'� �, a y g � � � a � <br />I_ANO USE APPLICATION M <br />SqE <br />PH=M2 Err, <br />BOS GISTRiCTS LSAT DEPq <br />t Q <br />Invoice d <br />CONTRACTOR /SERVICE REQUESTOR <br />RECIUESTOR <br />:-3 '�:� t _. `— "i <br />CWCtr d BILLim.- A04tr <br />BUSINEss NAME I <br />jam. t ,1 p <br />coewENrs:t1 'k)y75 exp(lvided. s'erilc <br />py�M Err <br />ACCEPTED BY: Z' <br />ONA <br />HoVk cr MAJLJm a ADDRESS <br />Assm&D TO.S <br />FAx0 <br />EmP6DYEE X: <br />DATE; I51a <br />i M <br />CITY r+ � <br />STATIF yip Oj a <br />K <br />BILLIM; ACKNO)XL .IK;FMENT I. Clic toWersigned property or bosimem uxner, operator tic aulborimd agent of same, <br />acknowktige that all site and -or projtxt specific 1=n%�,tRunmwTAi. IICAI.rrtI DEPAR1t•1I;NT hourly charger a.mAxiated with this prlo*t <br />or activity will he hillcd to me or my besinm a' identified tett this farrtt, <br />I also certify that I have prepared this applkaiion and deet the wA to be performed will be dwic in accordance with all 5AN JM%Qtmi <br />COUNTY' 0r&,rivnee (ixles, :ri candards, STA t and Ft:trl mt. laws. <br />APPLICANT'S SIGNATURE: LMTF! <br />1Praot!t tett' / llr %cws'%0%sERlt Om R,L twit! IMANAGLR © 01imm ArTillopuEoA m%i 0 <br />if A171LIY :1,17 is I" 1Afr %<JJLL- 11' tNl y', P"Wf Ofsath0 itatrox to sign is required rifle <br />AUTHORIZATIQN TO RELIi:Ar`SE INFORMATION: when applicable, 1, the owner or opetrtor of the property locaied at the <br />*ive site address. ficrch; authortle the relc st of Any :Ind all rc tihs, gcottixhnical data and,or environmentaUsite asscsvnent <br />infonnation to the SPLN 14JA 1 •r%: Crj4N ry I--Ntrtlttxvsttt,NTAt_ IIIALTIt Ilt:pnr nu -'.Nr as stmm as it is available and at the same tittle it is <br />nrtivided to me of my reprewwolativc. <br />IVNT <br />Ep <br />Z022 <br />COUNT <br />NTgL Y <br />TMENT <br />TYPE OF SERVICE REQUESTED: of l f /oce4 4 -ib o <br />Of S e � 16 <br />coewENrs:t1 'k)y75 exp(lvided. s'erilc <br />Pey)"It svj5?05 selo)ic tln GirpG1. <br />ACCEPTED BY: Z' <br />EmPtOYEE 0: <br />DATE: <br />Assm&D TO.S <br />EmP6DYEE X: <br />DATE; I51a <br />Dab SerY vice Completed (if &IF@* Qompt*tsd1: <br />St:nntt: COIX: D 61 <br />PIE: � b <br />Fee Amount,- S'(� <br />Antowtt Paid �S�o.GYj <br />Paytner�t Date <br />1 ZZ <br />Payment Type ��,� <br />Invoice d <br />Check 0 / �g (Q3 !� <br />Reeelwd By: <br />EM 48.02-025 513 F(VtM (t,o4en Roi11 <br />REVISED 11117/2003 <br />