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SERVICE RF-OL]FST <br />Type of Business or Property '-' FACILITY 10 Y <br />„E01ST 96;A5 <br />5TATtoN <br />oJQ <br />OWNER/OPERATOR <br />- -- <br />ut.TRAmAR IlVe. <br />CHECrt if PILLING A99PE3313 <br />FAcIUTY NAME <br />BEACon/ # 3756 <br />F� A <br />(set �) <br />SITE ADDRESS /3 `17.5 J E HW y 88 <br />StuffI <br />I' <br />HOME or MAILING ADDRESS (It DIH*renl from Site Address) <br />Zw <br />9/502 <br />SAN JOAQUIN LUUNTY <br />CITv ,V <br />D <br />STAT C zip 15237 <br />PHOMEGOc%>:'Fo� <br />559) Ss3 3235 EaT <br />APN0 <br />LAND Use APFLICATRIN9 <br />PROBE a2 Ear. <br />ROS DISTRICT LOCATtom CODE <br />CONTRACTOR I SFRVtr= ca=nt Icc•rno <br />ESTOR <br />Douc MA-55ARO <br />�— t / "T <br />CHECKII�INraADDRES3 <br />Es3 NAME nos EN6/NEERI,tl6' <br />F/3 <br />g1E� <br />942 3644- <br />or MAILING OR <br />0 7 W. AI- SM$ eDA AV. #203 <br />= <br />F� A <br />(set �) <br />92 3760 <br />l/R5gNK <br />STATE CA <br />/1 <br />Zw <br />9/502 <br />DuW, " Lz A NV111 N ur -rmI Ire.-.-: t, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific PUBLIC llEALT(I SERVICES ENVIRONMENTAL HCALTII DIVISION hourly charges <br />associated will' this project Ur activity will be billed to me or my business as identified on this form. <br />I also certify chat I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: - z7rf\_O -r--' <br />DATE: 1 —'30-11 <br />PROrERTY/BUSIN03 OWNER OPERATOR/MANACER OTHER AUTHORIZED AGENT PRO. "n 6x <br />VAPPLICiNT a not the BILLING PARTY, pruojofouthoriration to sign Is required Ttr1P <br />6Ul'HORJ7ATl0N TO RUEASE INFORMATION: When applUcablo, I, the owner 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HEALTII DIVISION as soon as it is available and <br />at the same time it is provided to me or my representative. <br />Reouesm- <br />�— t / "T <br />1 �J LTi <br />77777 <br />ETYPEO,F,,,S.,ER'ICE <br />• <br />NOV 12999 <br />SAN JOAQUIN LUUNTY <br />PUBLIC HEALTH -SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />uNRE: <br />COITR4CMRY S"TtME:MR <br />APPnoveo eY:EM►LOYle <br />/: <br />ASSIGNrD TO: <br />EMPLOYEE R:Dale <br />SeNlCa Completed <br />(It alreatly eompletetl):SERYIC£COOE: <br />U -�Fao <br />Amount: � <br />ld <br />Payment DPayment <br />T Yr) <br />Receipt S CheckA y <br />411 <br />v V <br />V( ice` <br />