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s V V & <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SLRVICE REQUEST 0 <br /> IF <br /> -TA 0 D 03 V-2 %1 <br /> OWNER <br /> /OPERATOR <br /> C!!a(M Cx�nn smocks❑ <br /> Fscil NAME <br /> ArEa,;;,;Z:.. %114 'frac 9sb�-G <br /> 511W 149"PINK <br /> How or MALM ADDRESS IM DIIhrnn Ran 8lb AIMMS) 3S80W G-ayt} Lim- W <br /> M <br /> 1 ml <br /> CITYA`aC C^TE ZIP cl C.)_0 <br /> Pt H Es'. APN a LAND USE APPLKATpM a J.JI/l�. <br /> l ao91 83.x-,260 <br /> PIM 12 Es'. IMos D6inM:T MOUTtoM DODE <br /> t ;Pt-A -ci 4 Z <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CWM M Ell 5.0.�s❑ <br /> Bt131rEss NAME PlDlaig �. <br /> HD Eor MAttam ADDRESS 1 <br /> 7 <br /> 9 <br /> Cfrr STATE ZIP <br /> ,I Rn_i.ING ACIQWMjEIN:1•aMFNf: L the undersigned property m bminess owner,operator m authorized agent of same, <br /> achmowledge that all site and/or project specific ENvuzotrD.lD•rr HEALTH DP3ARTWEENT boil charges associated with this pruiect <br /> or activity will be billed to me or my business as identified on this from. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SA JoAQtT: <br /> COUNTY Ordinm,<e Codes,Stmdm'dr,STATE and FEDOUL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> pacr tBusmassowertaE3 Oreruroa/AfsMAGaa❑ Oram Aurarntcutn AGswr❑ ldhic <br /> IfdPPUCANrissottheB t0�PI pr fof"Ikorimtion to sign is regaledWben applicable,L the owner or openmr of the property loabove site address, hereby So lmtze the release of any and aU res lts, geotechnical data and/or envimmnental/site information to the SAT+JoAQtml CamTY EtivrsONM rrAL HEALTH DEPARTt.(l as soon as it is available and at the samprovided to me or my representative. F <br /> TYPEOFSOMDEREODl <br /> COIaEMTa: O�` <br /> 841V <br /> HFq<r Ro UOS <br /> IV <br /> ACCEPTED BY: <br /> ErPLOYEE/: DAYS: /'A . �NrY <br /> torco To: .�_- <br /> EMPLOYEE a: DAM <br /> Asa /VT <br /> Dy Snrvlou Compl6lad (M Wsady aaknplses0): SaaLECDaE IB <br /> Pp <br /> P«Amount ` j —- Mnokmt P. /s .OD OftP^wd DO* 1 l <br /> .l P l Typ- }j' ,,, _ Invoke IS Ch.ek f <br /> /,`t t sa FORM(G~Rse) <br /> EW 46-02425 ?j "1�f <br /> REv6Ev/1mrzDDa I7yv11� �1 A �. !1 <br /> PVA 11P313� <br />