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aenvn.E NEUUL51 <br /> Type o1 Business or Property � FACILITY ID 0 ..i SERVICE R <br /> '6QE EST; <br /> V7 'i <br /> OWNER I OPERATOR <br /> Baunc PARTY <br /> FACILrTY NAME <br /> V-eoj <br /> r )9e- - <br /> SRE ADRESDS161ftf=lv/� <br /> StrM Numer OtreNon N.i KM�mr irpe SuiNr <br /> Mailing Address pf Different from Site Addressl <br /> XTry <br /> C T.r/'raSjATE <br /> PHONE 41 ur. APNN - LAND USE APPLICATION If <br /> PNONE fil <br /> D o> o�$ O r LOGAT off CODE <br /> CON _ <br /> REQUF.S OR BILLING PARTY Cl <br /> BUSINESS NAME - <br /> -- .. PHONE ft pT. <br /> MAILING ADDRESS <br /> FAx <br /> CITY ZIP 9� <br /> BILLING ACKNOWLEDGEMENT: I, the unders4ned property or 1$u 'el same, adonoWledge that as 0a afaor project speciri <br /> .+ PUBLIC HEALTH SERVICES EwcRCHmENTAL HEALTH Divism houdy Charges a b me or my business as Identified on this form. \ <br /> I also cerdly that I have prepay application and that the b be. JOAOAJ COUNTY Orldlance Codes,Standards,STATE an L. <br /> FEoEm laws. ;, ; {A <br /> APPLICANT SIGNATURE: DATE: <br /> IZE z u- <br /> PROPERTY IEUSerESSOWNER ❑ OPERATOR/ ER _ OTHER AUTHORIZED AGENT 13 } <br /> tlAaat.cwriTPotpw Amor or audnxhadorr to 31041$nWA!d rills �{ <br /> AUTHORIZATION TO RELEASE INFORMATION:yyhen applicable.L the ovmer or operator or Ne property located al tfle above she address,hereby authorize the release al <br /> any and aft results,geolechnlal data andfor enveonmenladsile assmrnenl Into illation lathe SAN JOAOU1N CCUNTY Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH Division as soon <br /> as R is available and at one Same time 11 is pmvWed to in,or my repmSenlaWe. (' <br /> TYPE OF SERVICE REQUESTED: <br /> SC 02firL C 5U!'fQiro/J — - - -- - <br /> COMMENTS: 6.Z`j_G G <br /> PAYMENT <br /> RECEIVEn <br /> SAN 10A0VIM CUUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE 0; tf-�o l DATE: 10 <br /> (2-10`7 <br /> ASSIGNED i0: C -EMPLOYEE 1 DATE: 2-O <br /> Dale Service Completed (If alrea Completed(: SERVICE Capt.:�C_((� f P y E:el 2 <br /> Fee Amount: b s'1!I Amount Paid v Payment Data <br /> Payment Type !G Invoice p Check N Receiyed By: <br />