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role I'le, <br />�Favlf-r- tzFc�tlr-�r <br />FHOOGISR revised 07/1C/99 <br />'Type of Business or <br />FAC[LfTY ID A <br />SERVICEQU # <br />.Property <br />5J'/9T /moi M.4Q7" <br />/l/ <br />19053 - <br />0"ER10VjFWki0R <br />BUM PARTY <br />FACUMNAME <br />— Q <br />S[TE ADORES <br />���� <br />j plriepo, <br />Sued Kx%@ <br />Mailing Address'(If piffc�t from Site Address) <br />CttYI n I L/`'%A <br />SiniE LP <br />CJ�7 DKA <� — <br />FWNE 01 � I «T. APN # <br />LAID USEAPPUCAmK# <br />P(/F�t7ONNSE #2 j /J LJA 1 ate. <br />Bo$ Dtb7StICI .� - _- _ - L>�•A7yC1]iCbDE <br />j )CONTRACTOR / SERVICE REWESTOR <br />tzEavesroR/LL jEY1Lsl�9r�/T �i 7-1G ,2�%��icZ Gc�•'r% �/ 61Lur�FAR> ' <br />BAsMESS tIAME <br />—T FAX # <br />[tea �zso <br />Coy <br />sTATE Zu <br />E31LL[ G iCNOtN[ EDG�MENT., 1, the undersigned property or busirK-S ownar, operator or authorhned agent of same, ac -knowledge that all silo <br />agd/or przl{ect specific F'y u c HEA1.T11 Sc -R%= EN%Vz( tTAL HEALTH DN1s*N hourty c}rargeS associated with tits projecf.or txYivity will be billed to <br />rria or mylb)sirje -s az Identified on this form_ <br />also cc ify that I: have prepared this application. and that th0 work to be performed will be done in accordance wit1T alt SAN JOAQUIN COUNTY <br />ObdrnArx�o codes, Sfarrdsrrls, rn <br />DATE-:_ <br />t vatTY l ciwN62 i O OPERATORY Mitt GM ❑ Ottmt AUll OWED AGENT Cl_ AP -co f�/�� �✓�,� <br />w �ON: <br />UAAICX.AM'bWthe-FMr G PAm—y pmolof audtodudoo to sign istequkvdH0L- E (NFO ATtON When oppbcable, L the owner or.operatior of the property-:ocatt:ct at UIe above site adclt��s, <br />hereby aryse of arty and all results,igeat�echrtical data and/or emlratmenta[/site aswSsaw mt tntomtatlon to ttv SAN JOAWN COUNTY <br />puf�uo HC,/LtN SEIturCEs' ENvtRoNt&WTAL HEm;�j Dmstom as soon as R is awaBaable and at the ame lime It Is provided to mQ or my reprrsentative: <br />Tiw- or S ggRv E REqut <br />tl I <br />. //V <br />�f <br />/l/ <br />COhtMEHT La <br />SPECIAL CONDii10N(S) or- APf'f om ElOTtrFR <br />— Q <br />i <br />RPR 2 719 <br />e . <br />i <br />, Hs, <br />SkN JOAUUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />INSPECTO S SIGNATURE: r <br />I <br />. j CONTRACTOR'S SIGNATURE: <br />DATE: I� <br />' <br />DATE:-- <br />ASSIGNE+-: I <br />Date Service uipleted I Oready <br />Lot <br />eomplaW).* <br />Ed['LOYEE A: <br />rn <br />p-� <br />St Rvtcc, Cots' <br />DATE:. 7 <br />P I E... 3C) <br />Fee Amount . i I <br />r �'��" <br />Amount F'ai�`-- <br />— <br />Payment Date 4-�3444-- <br />Invoice # <br />Chpck #. <br />Rece ved By:. <br />r <br />