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SAN JUAQUIN COUNTY ENVIRUNMLNTAL HLAUrll DLI'ARTMLNT <br /> SERVICE REQUCST <br /> Type of Business or Property FACILITY ID I SERVICE REQUEST it <br /> sR603al -7 (" <br /> OwNE OPERATOR <br /> CHECK It BILLING AGGRESS <br /> �.` <br /> FAcIun HANE <br /> SITE AUORESS <br /> y. <br /> I Ca <br /> (lore or MAILING ADDRESS (Ir unflarent from Slto Address) <br /> - _ 3VNI N,nnb r air <br /> CRY STATE ZIP <br /> QL> ons 4P3a <br /> PNaRt#1 En. AP N I O_L I I t O _ I LAND USE APPLICATION# <br /> > Wit- �a _ oa <br /> PHONE t2 - E'T SOS WFIVCT Lar:ATIDM CAl>< <br /> CON'T'RACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> GYMCKIf�ILLIMO AOOAl:sa� <br /> BUsmss NAME PHONE# Ear' <br /> NOME,or MAILING ADDRESS FAX t <br /> .>< ( 1A <br /> Cm SYATe zip <br /> oy5zMX- <br /> RILLING ACKNOWLF.943,1 M1I ENT: 1, the undersigned properly or busine" owner, Operator or authorized agent of same, <br /> acknowledge that all floc andim project Specula ENviHoNMLNTAii.HEALTH DhPART'MENT 1101111y charges associated With this project Or <br /> activity will be billed to Inc nr my bminess as identiried on this form. <br /> I P60 OCI iry shat 1 have pmparcd this upPlicalion and that the work 10,46 performed will la:dont in accordance with all SAN JUAQUIN <br /> COUNTY O,dinance Coder,Stand .,STXTE and LQUAAI-laws. <br /> APPLICANT'S SIGNATURE DATE: 15.- IU-Q-A <br /> PRuMAVY/UOSINLSSOM'NRR❑ Ort: a/MANAGLH -OTrrr.RAtR11Or1ZLDAcYNT❑ <br /> 1f APPUf.AN'! le Rnl N<: Rrl' proof of authari;ation to sign it required Till# <br /> ATITHORNIATIUK TO RE. RASR INFORMATION: When applicable, 1, the owner or operator of the property luxated al the <br /> above site addrtss, liemby authorize the release of any and all racults, gcotechnic:d data and/or environmental/site assessalcm. <br /> information to the SAN JOAQUIN COUNrY ENVINONMENTAL HEALTH DRPARTMENT as soon as it is available and at the sanx lime it is <br /> provided to me or my representative. <br /> TYPE OF SERVIC//////e���REQUESTED: ' <br /> 7 14 <br /> COYyEN � aE/03� 9 2eY3 aFC;ENF� �b5 94 <br /> 9D <br /> l l tiw'1. '�u5uc r+Er�1.�s <br /> :1 <br /> APPROVED BY: 1 EMPLOYEE 0: � Dill: r / ),Irk,Ix <br /> ASSIGNED TO: EMPLOYEE#: IJ <br /> . 'j <br /> Data Service Completed alreadyeom elad): SERVICE CODE: ra.T— I I <br /> Fac Amount: f Amount FuldPayment Da to n, 2 <br /> Vt <br /> Payment TypD Invoice k Chock#_ 1 7 3 Z Racelved or. J <br /> EEV41ED S-0 Y, � '—' SERVICE REQUEST FORM <br /> REVISED 6SDT <br /> r� <br />