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ougs flow Vignito f acting airsLearl <br />San Joaquin county Environmental Health Department <br />Application Form AP-ON <br />luinV NOM.. <br />FALLtCal;, -1AL'is.VP) • t L ilia <br />417 — V <br />Mtn ispitOMS00 LThOMI <br />or lawna4101 rAltr• —*t1ianpofempv riven ra- Seven, -^-opieerets.Th. <br />mm <br />lieetueetne ureireemoeeme - <br />rembihulored Woo m Memo Mile revertbro <br />nompwitutt <br />r•-u- ntent rime —FA stawsplat, , <br />I/ Mine PailY 10FandlIS, Owner ri fikedly Contact I 0 Prelrerty Ovine. <br />1 CIPmmety OtemIr J CI rosemattor Crieeeeset <br />—L <br />Contracter I C./brewer <br />hone Dane Onset <br /> oq q4611-lau, rue.70,411 6L, <br />Cil/Fadlthr Owner Dycmtad jin Properly thaw 12 canttactor OM:1MM Whig Party <br />Herne <br />r 0„ 1..1(k rt <br />oontrestor, inebtale type anallennse member <br />Fine Name <br />11,4 r c <br />Addrtis <br />CT:N.4" Cl <br />Phan, Phone <br />1I -02,7 <br />last name <br />V6If <br />Sk-L 00-c, <br />ktfriLt ay. <br />If comrade:, Indic:tempi and license member <br />LI <br />Slang Party I 0 Facility Owner 0 Facility Contact 0 Property CIVORtf CLArchttect <br />Us( name If contractor, indicate type and Barnet number <br />Bete ZIP <br />First Nuns <br />Addaess <br />rtane <br />BILLING ACHNOWLEDGEBAE.NT I, the undersigrued properti or business owner, operator or auction:rod agent of same. adult:Wedge that all site and/or praMst <br />specific ENVIIIONMENTAL HEALTH DEPARTMENT hourly chargic assaaated with this project or activity will be billed to me or rITY business as identified ori this <br />farm <br />I also certify that I have prepared this appriartion and that the walk to be performed will be done in sccordance with all SNI JOAQUIN ODUNTY Ordinance C. <br />4 <br />AprucAwrs SIGNATURE; .7 1." DATEL I Standards, STATE and FEDERALtaitLei , <br />_ <br />ye PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I. the owner at operator ef the property located at the above site address. hereby authartzt the <br />release of any and all results, geetechnical data and/or enwronmental/srte assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as It is available and at the same time it is pr cv ,ded 42 me or my reprer.entavve <br />(21W. <br />&waned 70 <br />(e(27-12_11 PE IV)* :on IS6•00 1 <br />Accepted 01 Lenked FA ID <br />ilecard hlaset <br />Tale <br />or