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SAN JOAQUIN C OUN-iry INviRoNmENTAL HEALTa Dic. PARTMENT <br />Type of EWriess or Property <br />FACMM ID 9 SERVICE REOMT 0 <br />OWNER I OPERATOR <br />CWCKIf8a.UNGAVI?RP D <br />r1r-cr-0 <br />FACILITY RAME (Ap�) <br />SITrtADoollass <br />f -3 Ll 2-S- sum mm -b-, MMU <br />L <br />nn <br />hil 0 <br />qga <br />-00 <br />I'lamEorMAILtHGAWRess pro <br />Solyd Nwbbww ...... linsetfleme <br />CITY <br />STATE Lp <br />PHQNE#1 FEW. APM# <br />LAND Use APPUcATx3u 0 <br />13morel 92 Far, <br />009 DCHTRICT LW-AnOWCODE <br />REaur!STOR <br />BUSINESS <br />HOME Or MAILwG ADDRESS <br />3 <br />CITY <br />Qyr-cK If ftvimr. AIfDREBa13 <br />STATE zip <br />BILLIN!g ACKNOWLPMEMPM: 1, the undersigned property or buAnss owner, operator or authorized agent of some, <br />acknowle4e that all site andlor project specific F-MVIPOKMZNTAL HEALTH DEPARTMENT hourly charges associated with this project <br />ar activity will be billed to me or my business as identified on this fenn. <br />1 &130 certify that I have prepared this application and that ftwo* to be performed will be done in accordance with ;,It SAN JOAQUIN <br />CouNn Ordliumce, Codes, S(andards, STATE and FFIDIMAL laws. <br />APPLICAW11"S STGNATURI;: DATE'. <br />PROMRTY I B4MfMNtG%VNEJt[3 OMATOR/MMAGElt 13 Orni:RA <br />urRosamaAcIMITE0 64 -ARL <br />1fAPPvCAIVT&tit 1h6A&&8'�Pfily Proof of 4affializada" to sign is regiffred Tirlr <br />AU't_A[ORIZATION TO RIEF EASE INVORHMON: When applicable, 1. the owoer or operator ofthe property located at the <br />above site address, hemby authoriac the release of any and all results, geotechnicall data arWor covironVar-rdallSitC asmnnew <br />infemiation 90 the SAN JOAQUIN COU19TY E14VIRON1611INTAL HEALTH DrPARTMEWr as soon as it is ovailaW and at (W same timet is <br />provided to me or my Mpresenta6ve. <br />TYPE OF SERV06 STED: <br />Commas- <br />Acce-rizo i3y.- <br />I EmpLayne N.- <br />Me- <br />ASSJGNruDT,O: I EMPLOYEE #: DATE; <br />T�SWMM <br />Vote Service Co ed (if already c9mPietid): CCW: <br />Fee AMOUnt. I Amount Paid I payment Date <br />Payment Type Invoice 0 I Check 0 <br />C H O 48-02-025 <br />REVISED 111171206S <br />PfE, <br />Received By: <br />SR FORM (Golden Rod) <br />