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SU0004864 SSNL
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SU0004864 SSNL
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Entry Properties
Last modified
5/7/2020 11:31:18 AM
Creation date
9/4/2019 10:15:22 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
FileName_PostFix
SSNL
RECORD_ID
SU0004864
PE
2631
FACILITY_NAME
PA-0500081
STREET_NUMBER
23315
Direction
S
STREET_NAME
BANTA
STREET_TYPE
RD
City
TRACY
APN
25013007
ENTERED_DATE
3/2/2005 12:00:00 AM
SITE_LOCATION
23315 S BANTA RD
RECEIVED_DATE
3/1/2005 12:00:00 AM
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\B\BANTA\23315\PA-0500081\SU0004864\NL STDY.PDF
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EHD - Public
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SAN JOAQUINU LINTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property �441 O <br /> PSN - � i �Nr� � 1 <br /> OWNER I OPERATOR .,. CHECK if BILLING S$� <br /> 30a-tA F GT E✓EGOP�I _, _ �, <br /> FACILITY NAME 4, ,I C OG /� GRF F <br /> SITE ADDRESS 'v SF'f /J�� AaA,0 r•4GIt 9 Seo <br /> Zi Code <br /> Street Number Direction <br /> Street Name <br /> I� HOME or MAILING ADDRESS (if Different from Site Address) <br />� EA= (2 v S ��� Street Number Street Name <br /> STATE zip 9 s <br /> CITY <br /> EXT. APN# LAN USE APPLICATION# <br /> IV <br /> PHONE#"I <br /> EXT. BO DISTRICT LOCATION CODE <br /> PHONE#T <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> D491V ZIMESA/e PHONE# <br /> � / Z <br /> E <br /> xr. <br /> BUSINESS NAME /�/ <br /> / /F`�/e / 4VJ6eLT/r / <br /> ROME or MAILING ADDRESS FAx# <br /> 71* STATE 4ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property Or business owner, operator or authorized agent of same, <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> acknowledge that all Site and/or project <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appl' tion and t the work to be performed will be done in accordance with all SAN 7OAQUIN <br /> COUNTY Ordinance Codes,Standards, E and FE laws. <br /> 0APPLICANT'SSIGNATURE: DATE: -1 <br /> PROPERTY/BUSINESSOWNER❑ OPER TANAGER ❑ OTHER AUTHORIZEDAGENT Title <br /> If APPLICANT is not the BILLING_� proof of ithorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: Wh n 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 enve nd at <br /> sa assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me Or my representative. <br /> TYPE OF SERVICE REQUESTED: T <br /> CommENTs: /�/��US � I; '/�� rfpAYMENT <br /> r <br /> SEP 2~00 <br /> G �OmUG" aMnr-��1 JOAQUIN COUNTY <br /> E <br /> OYEE#: 4 f 3� DATE k� NT <br /> ACCEPTED BY: L l U E <br /> CJ EMPLOYEE#: 097 DATE: �%T C�� <br /> LC TO: � �l n/5 <br /> Date Service Completed (if SERVICE CODE: PIE. 2 6_u�already completed): �� ��� <br /> Fee Amount: �FIrS f.S <br /> Amount Paid 9'7 Payment ate 4 yZ�d <br /> Check-4 �.3 Received By: � <br /> Payment Type �/ Invoice# <br /> 151 <br /> n. <br />
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