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Page 1 of 1 <br /> SAN JOAQUIN.COUNTY ENVIRONMENTAL HEALTH <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> `I/e a , r,t 2 Et/D�ivrlAL <br /> OWNER/OPERATOR <br /> J49V E-L /N E POL K AAJD !✓I/' . -Yp A/ <br /> FACILITY NAME <br /> O K L / <br /> SITE ADDRESS /Q7.49 / A � C K "TONE <br /> Street Number I Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4 ;A 5 7 <br /> Street Number <br /> CITY / / STATE <br /> PHONE#t L-IJ 7710/0.3 <br /> APN# LAND l <br /> (A 9 ) / 5 - 633 - 2/a.- 22 .23 <br /> PHONE 92 EXT BOS D <br /> ( Zv9 ► X77 <br /> CONTRACTOR / SERVICE REQUE! <br /> REQUESTOR <br /> DON 6-1 <br /> BUSINESS NAME <br /> C FSNE CONSLCL T/N <br /> HOME or MAILING ADDRESS <br /> CITY L OZ /4— STATE <br /> (� R c <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT <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 app ' ation and that work to be performed will bt <br /> COUNTY Ordinance Codes, Standards, E and FED a vs. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/4ANAGER ❑ HER AUTHORIZED Ai <br /> If APPLICANT is not the BILLING PARTY, proof of auth rilation to sign is req, <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner <br /> above site address, hereby authorize the release of any and all results, geotechnical <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT as soon <br /> provided to me or my representative. <br /> file://C:\Documents and Settings\mescotto\Local Settings\Temp\DMCI\DOO\2.JPG 4/2/2013 <br />