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l <br /> 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bushms or Propetty F)d6T0J j. MIC FACILITY ID S SERVICE REQl1EST# <br /> 'NfAMA - NOVIES A FA 000 q P d' SCZO�`153$5 <br /> owltERiOPERATOR �o- 000 CKMKffftmLm=E3 <br /> QfOonoft : Cha fAAft USA, 184 <br /> SnAWWW3 p HUME LA0immmow- L] <br /> HONE or Wmm Atm us (H DWorsnt*om Sks Address) <br /> 84vL NWmLNr <br /> Crff STA zw 75083 <br /> PIIONEt)1 T APH 0 LAND USE APPLICATION#x <br /> lqn� r <br /> Passim [ar: 008 DISTRICT LocaTiov+Cane <br /> � I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> I <br /> RmlrsToR Ct+/W; '#?8P: cvva acute <br /> AME <br /> pias- I O <br /> t�eMrer MMunc ADDRESS FAX I <br /> ( 00, <br /> CITY PLAWD STATE %X LP 709,3 <br /> IQILLING&MOWILEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL,HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 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,STA'T'E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: JU4914 Q&kme DATE: <br /> T <br /> PROPERTY/BUSINMOWNERD PERATOR/MANAGER 13 0TuzRAvrmmizcvAG£4T5eDW OPM9 rY1MA i <br /> IjAPPLXANr is not the#ALINGPAAT f proof of authorizadon to sign is required Title <br /> When applicable,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 environmentallsite assessment <br /> information to the SAN JoAQum CouNTY FNVMONMENTAL HEALTH DEPARTMENT as soar as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SOM&REQUESTED: <br /> cam C gSift '[04 ItMnMJ%AN 'Q virmLa• &S-0Z k0VIr VCR= t wO P <br /> -gWis : WPACW 63aSTl1 & COPMWOP SU40 84 A=M10k <br /> 5ft AMA. 'qUG Er�Ep <br /> r P j ►, CAP< 4 y 20 <br /> � 10 <br /> ACCEPTED BY: 1�'//j� EMPLOYERS: DATE: n�oE^ eU by <br /> AssLa Eo TO: ``5 +r EMPLOYEES: DATE: � 3��f• "N�,.> <br /> Data Service CompleW (R already a mpk tsd): SBMM Com: ;"13 ] PIE: Am <br /> Fee Anioun aZ Amount Paid Payment Date 1(a <br /> payment Type (;rc(R;�' Invoice S C a 4 J[11>-3 Received By: <br /> EMD 48-02-025 SR FORM(Gcdden Rad) <br /> REVISED 11117r4M <br />