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05/09/2009 PI2P 1::09 ?A% 9094663433 SJC BUD --- Stockton Sery Eta :A Cc m <br /> ��� <br /> SAN JOAQUIN COL'IVTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID@ ` � SERVICE RAWEST <br /> Type of Bualnass or PrOpmiy �1 L <br /> OWNER ✓y - a cKukuBYLNC -s <br /> FArl�NAME <br /> SITEADDRESS/5- Aw— <br /> c <br /> s[rvw <br /> HOra�Or MkLWG AOCR 45 III D(Nmoot baro Site Ad[ryoso) <br /> Swa[Nu,Tor <br /> Cm STATS XIP <br /> PKEDIE01 APN6 WO Dee APFUCATI.".NF <br /> I I <br /> PaC:+Ed2 Eu, tYJ90PoTPICr LOGA'tOry CapE <br /> I <br /> COri1TRAC1'OR/SERVICE REQUF.STOR <br /> REODEMR c,�sata i@A WA AT,I � <br /> HOME en. <br /> BtWNEb6 NAm C <br /> HorrE m MAumo ADDRESS c' FAT <br /> S <br /> Crry STATE ZIP <br /> BILLING ACRCNOWLEDGEMENT:1,the undttslp zd p[operty or busiaeae owner,operdtur or atlQtorEW atcut Of sem. <br /> uknwwkdae than all sue aadler project specific ENVIROHMPNTAL HEALTH DEPARTMENT hourly ohalgas asaoeiated wuh:his project <br /> oraotivity will be billed to me rn MO'bnsiuus m eri ifiedou Ibis farm. <br /> I also attity that I have ptgmttd Ibis applicttio d dial the work to be performed will be done in accordance w:th all SAN 1QAQUIN <br /> COUNTY adiomu's Codes,Smndm'*,STATE W. ntAl.law6. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PIlOPeNCYl stalnE9s Ownaa� <br /> 0 <br /> tw.en1 /. W+ Qmt Omae AVl7temzrp ADYlT� <br /> ffhPPUCANTfS'neY 1110 BP/MO P, <br /> RIY.prop p ! rid, <br /> A UTIJORIZATIO TO R6LCASE IJYFORMATIONt Whoa applicable,1,the owner or Operator of the property IOculA at the <br /> above site addreu. hacby authorize the release of any and all malts, 90016chnical data andlor mlvimllmarinUs:lc aasossmeat <br /> information m Ibe SAN IOAQUW CgJNTy ENVL 0.1.4 hTAL HUALTH DEPARIU-NT as boon as it is available and at the same time it <br /> provided to me or my tapma t iva <br /> TYPE DP -G YME T <br /> RECEIV 7D <br /> APR 2 7 010 <br /> SAN JOAO IN(OUNTY <br /> AL <br /> AccapTao Br: E sPEOymt DAIS: ENT <br /> ASaIGNEO To: - .YpCovee& 2 DAM <br /> Dake SONloa Complatad (k ad omplmod): PIE' C) <br /> Fad AmaUnt: C) Amenllt Pate 3 1,5 — gyaWllt L 2 W <br /> payment typo <br /> IovdG9t Clawk0 I () ROGOhIolt�f': <br /> SR FORM(Goodin Red) <br /> EHD 4a-M-025 <br /> REVISED 11/7712Wa <br /> Z 99Z890L999 6u1Jeew6u3 A9AOO uq4 80 01 9Z Idy <br />