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FkxiivName <br />SHE ADDRESS <br />STATt <br />La«> Use Affucatioh • <br />Requestor 0 <br />Business Name <br />Chy State ZlR< <br />APPLICANTS SIGNATURE: <br />VcrH/yi <br />Employee*: <br />Fw Amount. <br />invoice*Payment Type C2A- <br />SR FORM (Gown Rod)EHP 4S-G2 02S <br />REVISE3 11/57/2003 <br />location com <br />_OI <br />FACtUTYIDS <br />_____cm________ <br />Pmowei <br />(-7/4) <br />P»«0*S2 <br />(> <br />BOS District <br />ex? <br />CONTRACTOR / SERVICE REQUESTOR <br />Ttpe of Serves Requested: <br />CoaMNn- <br />Etaei-OYua: <br />Sennet Coot: <br />t3>cx <br />Cm Br<c, <br />Cli <br />tTT <br />SERVICE REQUEST tt <br />e>iLcc'79^o^> <br />Cnecx tf Baxwp ACoress D <br />rT/cH <br />Fax# <br />( I_______________________ <br />CA- <br />BILL|NG ACKNOWLEDGEMENT: L th* undersigned properly or business owner, operator or authorized agent of same, <br />acknowledge that all site and or project specific Environmental Health DFJ’ARTMFNT hourly charges associated with this project <br />or activity will be billed to tec or my business as identified On this form. <br />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JQAQU1N <br />CGCNTY Ordinance Codes. Standards, STATE apd Fedfral laws <br />Accepted By: <br />Aas»G*to to: ________________________________ <br />Date Servlca Completed («already completed): Swtct Cost: CXp ) P1 <br />\ <0'Xd° AwOM"> Patd7S'/S& 60 I ^y"—" p** 7/31/1 S’ <br />“ | Received By: <br />I Vk c. . <br /><^A/W&vk <br />______________________L- nl <br />ARha <br />0 <br />2018 <br />1/^6) ok <br />Date: _ 7/>y//r <br />Propf an / Bi’mntss (TwkkrD " OrtsuToa / MaNagui Oriua AtrntoauKS Agixt Cy^fykTi^Nd ygerm//"t) <br />If ArrUCANt is not the BILIMG PAKTl. proof of authorization to sign is required ' Title <br />AVTHORIXATION TO RELEASE INFORMATION: When applicable. 1. 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 cnvinonmental/'site assessment <br />Information to the San JoaqL'IN COUND Environmental HEALTH DipaRTMENT as soon as it is availabiMnd at the same time rt is <br />provided to me or my representative. <br />rCrH/yi________________ ______ <br />________Slrwi Mm <br />Cfi. <br />lype or susmeaa or rroparty <br />2jC,V<xi\ Cc^nve'vi’e/^cc. SAc/v-C <br />Owner / Operator <br />Oh Cmtt/vn <br />^9^ <br />o>»—i aiMHitiT <br />Home or Majuro ADDRESS (If DWterent from Site Addresa)pc? (2>o< t| <br />Ch<^YT/v\ ft. i»3 <br />0,^.0