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'f SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A O CE REQUEST/ <br /> YTItT nJ S <br /> OWNER OPERATOR CnecAx66YBdOQatal® c <br /> ND /Nt+ <br /> FAottnNAME �rL SuPQ�METvIS <br /> SITE MDREEs NZ3 b N . q c, �'wA. T 6 <br /> as..t MunMrMMPCUM7" <br /> HOME or MAiLem ADDREes (x Different from She Address) <br /> City STATE Z$P <br /> ItltonE tl1 E*'• APN a LAW USS APPLICATION/ <br /> (ZD9 l 8�S Ir3y <br /> PMK#2 E". We DRTAftT LOCATM FADE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REareSTOR cREcrtxBi,AtDAoatass� <br /> BumEss NAME Rtpte� <br /> HOME or MAHMG ADDRESS FAX# <br /> 1 ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or suthorbxd agent of"M. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also ratify that I have prepared this application and that the work to be performed will be done in accordance with all SA.N;JOAQL'N <br /> COUNTY Ordinance Codes,Standards,STATE and FED laws. <br /> APPLICANTS SIGNATURE: — DATE: 10'IC-212 <br /> PROrERTY/BnSrNEsOwNERP OPERATOR/MANAGER 0 OTRRRAuTHomtzeo AGENT❑ <br /> IjAPPIICANTis not their" GPdRT1:proof of authorization to sign is required Tirte <br /> AUTgORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental"site assessment <br /> information to the SAN JOAQt1IN COUNTY ENvuLoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. jM <br /> Ay <br /> TYPE OF Soma REauEsTED: � CE/VE <br /> COLVEM: �iv/n/1Z /^.sOFL� ' Ott D <br /> 3.9NJ0 `O Z�ZQ <br /> H Or RONMEN UNN <br /> EMPIoYEE/: kDATE: `ACCEPTED BY: _ E�t��ASSNUIEPTO: V ` PIE:Data Semies Completed (x already DomPbrted): SalncEnt POW t)S2 - 02 02.0 <br /> PWM*M Typo C C Invoke RCh"k AMd By: <br /> J- .J <br />