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SAN JOA 91WCOUNTY EN(i MONASE <br />AL HEALT EI'AR�ENT <br />SER W- WE REQUEST <br />fiype of Business -or-Prt?perty <br />FACILITY <br />ID # <br />SERVICE REQUEST # <br />o 6C! 9 C) <br />QkNNI�I OPEfATOR <br />r <br />CHECK IfEPILLfNG.AhDRESSLsi <br />— <br />$`S E ADDIS§ <br />k1 <br />in <br />. t ., Street Number - <br />Direction <br />Street Name <br />CIt <br />Zip Code <br />h� "I r F1Q]VI t7C!MAI4ING ADDtt�SS (lf Different from Site Address) <br />-� <br />Street Numi�r <br />Stree Name <br />STATE ZIP <br />NONE1 aM .UXT. -APN # <br />LAND USE APEYL APPLICATION#: <br />__2�' <br />— _ <br />$� tP ONE2 FXT ' <br />BOS DISTRICT <br />LOCATION CODE <br />EO CTOR / SE tV7[ <br />-E ] EQITES OR . <br />� <br />lEtUESTOR <br />HECK if RI LING ADDRESS <br />" U' S1N S15 NAME r <br />PHONE t xr. <br />(4l�Co <br />(7Mpr�VlliILiNC�ADDRESS <br />.,ICITY <br />.. <br />STATE .. Z!P <br />.Bv LTN A� LF EII ENT I, :the undersigned'property or <br />business owner, op, gator or authorized agent of same, <br />acngwledge that all:s�te and/Ar projeet specife EPdVIRQNiVIENTAI HEALTH. <br />E]PARTMENThourlycharges ,associated with this projector <br />Y 4 .. <br />c.' En will be billed.# me-mebusinessasadenfified_onthis.form ... ..._ <br />i also-ceiti£y that Z have prepared,this applicaiion and that the work to be p�erforined <br />will be dobe in-acco .dance with all SAN JOAQUIN <br />' � � <br />GOiT%I'1LY �rdznanee �'bdes tafzdgrcls ST11TE and. FPt]F�i.AT, la ws. <br />' ' <br />r <br />t sx'�CA1�IT'S.O1�ATl1 <br />9 <br />; L <br />�ROIS) jYTY/BUSINEDATE: <br />SS �wNERL 1-.%10 PERr1TOk/,,MANAGER ` OTEm <br />I'AuTao=D AGENT <br />If 1'P,.LIGiNT. not.tlie�lILINGPARTY proofo� authorizati <br />nib sign is required Title <br />A7iEt)< ` T>i�T T€112E7�iC ORA'it3N en a _hcabl <br />_p1� <br />d <br />the owner oropera tor o fhe ro er located at the <br />- . _.l�__1? _-Y- --- <br />ironrnental7site <br />--=�6neiess t r tau adze az ease any.; . al :t xesults <br />...geotec : cal . to or e, assess mens <br />�',-;�.�•ii�'Of1oi1 tc3�tlie �i�'t�1 JDr� GoUNTY �1:IVII2.ON14fENd'A.L`HL3AT.TH DEPARTMENT <br />I <br />�YiENT-as soon.as it.is'avai a le an .at the same..tune It is <br />r�spro!ide ytoors p <br />` xnyxc re?e lve; <br />� - - <br />^. T <br />`g#s _ ... <br />ECEIVED <br />i <br />L <br />.S`AN bAQUIN CO, N <br />E VIROM15NTAL N <br />H DEPARTMENT. <br />kI 'CERTEDIf \f <br />EMPLO <br />C <br />.�•; <br />Ccrnp1.` a (Ifalread completed):.: ' <br />SERVICE CODE:(1 Cd <br />PIE:. '1'3 <br />. <br />P.. _ �... <br />V <br />ee� „rlotint mou Paid <br />3 <br />, .: yn1 hit. Date <br />Na e <br />r+ <br />l ,.p �rnettl Type Inviifee # Check # <br />eretvAd By <br />. <br />1 J � 5 p: •..' <br />I�. <br />•r. �` :: if { ; { it+i+i iht+.-...,...: .9...1: ,._.. ....,1 cif+MA hxi?A�/t° .rt I^ tM. <br />4 <br />• t .f. f I :d r y., <br />a <br />... -s;!''. r. : i• . t i k ,, i � � t r. e -� .•ice i- � i.. t t <br />v <br />