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kj <br />Type of Businoss or Property <br />OWNER ( OPERATOR <br />m <br />• SERVICE REQUEST <br />r, FACILITY 10 # <br />FActuTY NAME F <br />DRESS - <br />SrrEAD4/ - Al <br />1501 <br />S4MNltM.r Cirea}on <br />MaiJing Address (If different from Site Address) <br />CETT o <br />PHONE #1 err. <br />(>V ��t� - 41 t et l <br />PHONE #2 t:zr. <br />( � a <br />REQUESTER <br />LT <br />fGGA. rd u <br />BUSutESS NAME (� <br />MA$tG ADORESS ^ I A <br />')(? 1C� I 1 <br />V ,Gk t Un <br />APN # <br />91 <br />SEF <br />STATE„ ^ LP <br />LAND USE APPUCATzm ## <br />YS;VMTRJCT <br />CONTRACTOR / sERVICE REQUMOR <br />0S, -r() Q/ F1v";.� <br />BILUNG PARTY 0 <br />Svpt 0 <br />�53�G <br />LOCAT10NlCODE' v <br />1- <br />7T R- <br />ee <br />PHONE # EX. <br />t G <br />t r U FAX # <br />CITY <br />�r,rcS T E <br />BILLING ACKNOWLEnGEMENT: <br />I. the undersigned Proporty or business owner, Operator or authorized agent of same a LPA <br />Putiuc HEALTH SERVICES ENVIRONMENT TH QN1,,1CN how ly charges associated with Ibis ck"O*ledge ilial 94 site and/or pMjW speo1c <br />prOICC! or aCtV1, y w� be billed to ma or my business as tdenUfied on this loan. <br />I also r~. Vl fat fave p a -cep r lSOrt 3 V. Vta work erformed wIll ba done in ac=dance with all SAN JOAgUw COUNTY Ordinanc0 Codas, StenCards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />DATE: <br />PRr�PERTYI BUSINESSQrMER 0 �"�"'" <br />-RAT $ OrHEaAuT cauEoAGENT 0 <br />W A --r w r iz nit iter dUt_r P = propr of auuWdudon to slpn f1 rnu Ind Tills <br />AUTHORILATIQN TO RELEASE INFORMATION: Whsn appllcaNe, I, the Owner or oparatorof the property located at tris abm+0 silo address, hereby authorfza the release of <br />any and -4 resuu5, geolemilical data and/or env(ronmer,tg 3M assessment Inforrnatlon to the SAN JOAcuw CcvNTY PIMuc HEALTit SEAVtCfis ENviRONMENTALHEALTH DrytsiON as soon <br />as it Is Ovaitable and at the same time it is provided to me or my repmsentatfve. <br />TYPE OF SERVICE REQUESTED. C �� <br />� 2s <br />COMMENTS: <br />INSPECTORS SIGNATURE: <br />APPROVED BT <br />jAPPROVED BT:. . <br />IGNED T0: r "6 Jr/ <br />•Date Service Comple (if alreaJ completed): <br />Fee Amount: Ca <br />Payment Type Invoice # <br />CONTRACTOR'S <br />EMPLOYE_ 4: <br />EuPLOYE° #: <br />EmPLOTEE #: <br />Amount Paid .Y,��/ �; <br />Check # <br />DATE: <br />DATE: I <br />DATE. 5 <br />SeRvtcE CooE: ' <br />Payment Date <br />PAYMEN 1 <br />R ECE IV EC_1 <br />SAN JOAOUIN COUNT` <br />PUBLIC HEAL ( H SERVICES <br />tmR%,,mFNTAI HEALTH DIVISION <br />�S P r E: a�D$ <br />Received By: <br />P <br />