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JAN JUAgU IN %-UUN IV LN V IRONMEN I AL IIEAL I-H LOLVARI:MEN I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE REQUEST 8 <br /> �2ooro3 �� <br /> OWNER/OPERATOR <br /> M:tRIL.JtJ EGE`(Z CNEcxH&uST0A0dtESe® <br /> FAcamNAltE E6El=P(ZOPER-1Y <br /> SrrE ADomss 7-.100c) ni. I yyttttKJ 1 U-C p>. <br /> CtJEN1Ef.JTS qs 22"? <br /> � <br /> st NumWr <br /> HouE or MALmG AtwREss (If Dmerem from she Address) 1,2-q S <br /> N�m�ber <br /> CITY h,"PeWI p o STATE C.A 73P 9 S Z2-0 <br /> PaoaE M Ext. APN a LAW Use APPLICATION 0 <br /> (Zvi ) 009- 180 -a-4 -T -0$ r-T-- //- z"✓ (-��'� <br /> PWW 92 En. 908 DISTRICT L.ocAT10N Com <br /> ( J <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR INW4 CLO CNECX If <br /> BUSINEss NAMEt,t\w OfK. GSC0ETM?-CrI-JAAENxrf1%L Pry! . <br /> ase 31orl- 03`1S <br /> Home or MALm ADDRESS (40-4 vi- O&Y-- Sr- FAa1 <br /> (7..01 ) <br /> CITY Lot>I STATE CA ZIP 9 S 1-4*0 <br /> BILLING ACKNOWLEDGEMENT: 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 trilled to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar �STATE and FEDERA Taws. <br /> APPLICANT'S SIGNATURE: A c: U a O - 7 a \ <br /> PROPERTY/BUSINESS OWNER❑ OPE TORI AGERO RAtruc ENT❑ <br /> JjArrucAnrisnottheBirGPtxTT.proojojaWhor losJgTeisregnbed Tice <br /> AUTHORIZATION TO RELEASE INFORMATION: When a licable,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 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 SEIMM REWESTED: REVIEW S,JeFr CZ +SJ860i4F^CF- COY-Me%MIIJPET101J R'C:eo R-i <br /> COMENTS: � ,� �; I ( 1 RECEIVED <br /> � �r,% ✓It3a C, 1 „two , OCT 2 b 2011 <br /> N7 G L" o d <br /> y,Nyo ROOM N-� <br /> LTH OMIIE El <br /> "''((((YYYY�✓✓�� d. �NSEp�LTH OEPARTME 1 <br /> ACCEPTED the(\ EMPLOYEE N: DATE <br /> Asm"r.o To:, � � �' EMPLOvea the DATE: <br /> Date Service Completed (of already completed): SOME ODE: P/E <br /> Fee Amount: Amount Paid 16,2_5Z, 0p I Payment D111110 W(-2-(o (I ( <br /> Payment Type Invoice S Check 11 l Received By: <br /> Cun JU M AOC CD Cn01A fn.w..0M1 <br />