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AMdl,8661M%81 r tpelty X'fua I leiff JL . . .lam <br /> -7?'9 6200 71 10 I I <br /> OWNER/OPERATOR a <br /> � o G¢cK if&Luxe ADDREss0 <br /> � 1 <br /> FACILITY NAME <br /> 2 <br /> SITE ADDRESS I rr" 11W� gS33� <br /> rr��rr 2 Dlreetlon ''�^1 O reef Name <br /> aA a� Stied Number W V cm 1 a code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stied Number Strut Name <br /> CITY .STATE ZIP <br /> PHONE#'1 APN# LAND USE APPUCATION# <br /> (209) Y)+H40V <br /> PHONE#ZEx. BOS DISTRICT LOGTION CODE <br /> (20199 8 2 <br /> (0 <br /> 2y <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR n CLARK If BILUND ADDRESS❑ <br /> WILS 1 / <br /> BUSINESS NAME l J �" __ FLV j-„ PX ;j� / / I Ems. <br /> HOME Or MAILING ADDRESS , Yi 1 CJt 1 FAx# �S` 4�0 <br /> CITY MY\kem STATE 7 ZIP 9 S33b <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and thaythe work to be performed will be done in accordance with all SAN JOnou1N <br /> COUNTY Ordinance Codes, Standards, S nd_FEDERA I . <br /> APPLICANT'S SIGNATURE: DATE: 2�z�I <br /> � <br /> PROPERTY I BUSINESS OWNER4 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> ff APPLICANT IS not the BILLING PARTY, Proof of authorization to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to <br /> me or my representative. r p �.X/ <br /> TYPE OF SERVICE REQUESTED: '± � SuL 4 /tYI pq <br /> COMMENTS: F CF�FD <br /> FB Z <br /> M�.�DUMB?p�S <br /> AiyF ,4,'h), <br /> EA? <br /> ACCEPTED BY: EMPLOYEE#: 9U7 DATE: <br /> ASSIGNED TO: rn Al�7McL� EMPLOYEE#: 5 a (p DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0&1 P I E: I� 02— <br /> Fee <br /> ZFee Amount: 1 e3 D Amount PaiA/3(),OD Payment Date � �.- <br /> Payment Type ��_ Invoice# Ch # 62. , AI'-7/6 Received By: <br /> ll -2-(7 -710 <br />