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`e .:T <br /> t SAN JOAQU COUNTY ENVIRONMENTAL HEALTH'— —;PARTMENT <br /> SERVICE: RE�UEST <br /> Type of Business or Property FACILITY ID.# SERVIC QUEST# <br /> s yr-73s7 <br /> OWNER 1 OPERATOR <br /> Mr CHECK If BILLING ADDRESM <br /> FACILITY NAME <br /> �Bi-lieri-Pro e - <br /> SITE ADDRESS 17815 E State Route 88 Clements * ,}95227 <br /> Street Number Direction treet Name Ci µ Zip Code <br /> HOME or MAILING ADDRESS llf Different from Site Address) <br /> P.O. Box 604 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 952U�= <br /> PHONE#1 ExT APN# LAND USE APPLICATION <br /> [ ! <br /> 1019-11 <br /> PHONE#2 EXT. <br /> CONTRACTIII� <br /> REQUESTOR <br /> BUSINESS NAME _ <br /> Mail 0. Andt-rsnn and Aq-.f)rIrL—Jq-- <br /> HOME or MAILING ADDRESS <br /> 209 369-4228 <br /> CITY <br /> Lodi <br /> BILLING ACKNOWLEDGEMENT: I, the undersi� ile <br /> acknowledge that all site and/or protect specific ENvix �;et <br /> or activity will be billed to me or my business as identih � � C7 dieW <br /> I also certify that I have prepared this application and tt ; <br /> IN <br /> COUNTY Ordinance Codes,Standards STATE and FERE. <br /> APPLICANT'S SIGNATURE: <br /> �C <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANA <br /> If APPLicANT is not the BILLING PARTY,pi s <br /> AUTHORIZATION TO RELEASE INFORMATIO] _ /�j 1e <br /> above site address, hereby authorize the release of a <br /> information t0 the SAN]OAQUIN COUNTY ENVIRONMEN' <br /> provided to me or my representative. <br /> TYPEOF$ YICEREQUESTED: SQII Suitability Study a��.� V <br /> CDM s: <br /> Please review the following Soil Sulrrt <br /> fee of$186. If you have any questic <br /> Dave v� 7 <br /> �o L <br /> ! <br /> - <br /> APPROVED BY: <br /> ASSIGNED TO: 1✓kJ 11'f �� !�/ �9'�/ '� �Gr <br /> Date Service Completed (if already completed): <br /> Fee Arnount: oo. Amount Pi. �✓ <br /> A <br /> Payment Type Invoice# <br /> EHD 48-01-025 <br /> REVISED 6-5-02 �"` ' "' <br />