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SAN JOAQUIN CouNw ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busimas or PropertyP,ZFAMM IDA J ICE REWE <br /> r Dow <br /> OWNER/OPERATOR dAasNBauNa AaDr2sa❑ <br /> FA rrtlaNE � 6 <br /> SMADME" LOGS IMMKftI�SM&axo `� kit ,� "fr`o. I <br /> HonarMAsam Anvan promoromrmms"Addreeay '1'1I RIc�rdS s' '- <br /> -j�-,� O(dti N /yam r� [`�}.1 <br /> STATE <br /> IOMtE f tJ��—Vr��"J( � APN# LNm USEAonleragx# <br /> tar. 80.4 DmmCT LOCATION COVE <br /> f <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR . <br /> S � CMECFR BILlNO A0agE69� <br /> BUAINEa;NAME PNOpEP E"*. <br /> ROME"Manse ADDRESS Full <br /> I <br /> CRT $TATE zP <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same, <br /> arim avlodge that all site and/or project specific EMmOswei-ru HEALTif MPARmENr hourly charges associated with this project <br /> or activity will be billed to me Or my bushes as identified on this form <br /> I also certify that.[hat¢prepared this application ail that The work to be performed will be done in accordance with alt SAN JOA" <br /> COUNTY Ordinance Coda,Standards,STATE and FEDeRAALL laws. <br /> APPLICANTS SIGNAh`l <br /> TURE: :_— `,� DArzr I a a® - i q <br /> PRO"xTv1BLSLY6560w.nLT10 UraaArov;mmA 13 0r1ERAMADIUMDACENTO <br /> /f AFFCTUATysaorr#eStUM;AaRrr.proof ofautrorization rosign is reynfmd MI. <br /> AVTHORIZATION TO RELEASE INFORMATfUN:When applicable,T,(be owner or operator of the property located at she <br /> above site address, hereby authorize the release or any and all results,gwitchnical data andtor environmedtaVshe assessment <br /> inforruMon rO the SAN JOAQUIN COUNTY ENYTROx.v&%-rAL He-ALTA DEPARRRPxr as soon as it is available and at The sura,time it is <br /> provided to me or my representative', <br /> TWEMSERMEREWEim C � ...jpAY1 MENT <br /> Covvs m. R IVED <br /> DEC 3 2019 <br /> S,IJOA IOINCOUWY <br /> ENVIR NMENTAL <br /> PARTMENI <br /> ACoevrEDBr. EMPLOYEES: DATE: <br /> ASsmumTo: �� �� EMPLOYEE#: DATE <br /> Data Service Completed (if already eompmted): SERVCE CODE: PIE: <br /> Foo Amounk \S2.— Amoont Paid S2! Payment Date 17 <br /> Payment Type LC lmroice# Check# Recahnd By: <br /> EEM SED 1111 HlTLI�,�.* I D 2 68 Z,ZO-7 SR FORM fOolden Rosy <br /> REVISED 1111 <br />