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' i7A1�!�J VAS V11V<..V U1V 1 Y i'.iV V��tkli�llV�L*i�l,E1L i1�AL1 t!LL'YAK 1 LViI'.L�1 1 <br /> SERVICE REQXTEST <br /> Type of Bushtess or Property FAC1U'f'Y ID# .- SERVICE REDDEST# <br /> IrL9 5i deft / 5CZ-6VV <br /> OWNER► CHECK It DRAJIGG ADOWSSE! <br /> Mi- nee <br /> FAC nT f+M <br /> WEEAmms ��DD <br /> ��.. Fakeg/zOnd 1''�OvGI6y-�' <br /> s <br /> HOME or'Wt LM AWREN (it DMWrent tran site naaress) <br /> CITY � �� . Ztp <br /> 13M EN APH# LAND USE ApPLICATM s <br /> PHOT 12 EXT. BOS OtS Rwr L ocATww Coop <br /> c ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> �-- ❑ <br /> REOEIES�R �. r^t�t•e ���y v�,v� CHECKII!Ba.�wc mess <br /> Buss NAME �. E". <br /> 9 3 l- r 3 '7s <br /> HoworummADDRESS Fuc# <br /> !S3.3S- 50 /a, , /YxYi -� W k ( ) q-3 <br /> [ -- z 3 <br /> STATE <br /> C� �'t`�c k� G,� 9�?� <br /> _BILLING ACKNOM4i M LINT: I. the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMEWr hourly charges associated with this project or <br /> activity will be billed to we or my business as identified on this form. <br /> I also c�rtify that I have prepared this a tion and that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordiiuvwe Codes,Standar ATL and REDERAL laws. <br /> APPLICANT'S SIGNATURE: I DArE: l �� <br /> PaoPZM/BUsV4zss OWMME3 OmRxrotz/MANAGER ❑ Onma AumoRmw AGe rr <br /> IfA'PPGfCAM is not the BI N►___�_GPAR7�proof ojautlwrizalion 10 signis required 'rifle <br /> AUTHORIZATION TO RELEA IjiFORMA3JON When applicable, I. the owner or operator of the property located at the <br /> above site address, hereby authorise the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infortnation to the SAN JOAQUIN COUNTY ENV1ltONMEN'TAL HEALTH I)EPAmmENr as soon as it is available and at the saLne time it is <br /> provided to me or my repre entative. <br /> TYPE of SERVICE REQUESTED: �e v'i Cc <br /> t OMME rrs: D SGt��7�GC r` SpA ENT <br /> 3/i/•5 RE�4vED <br /> SAN SaAOUIN COUw`l <br /> .ir++.� vM NMENTAL <br /> Awn BY: �j L t k-4-- yeaq t�°YeE 0: 3 z/ SLP CS a S <br /> Asslt so: ,.�,4 EmkoM#: MTS z Cs( 0 s <br /> ' SEMOCECW- 2-- PIE: Z( c I <br /> Data Service Comosted (If already campy): Sz <br /> Fee Amount: f ��• : Amount Paid ' ( Payment Date <br /> Received By: <br /> Payment Type L Invoice Check# :< ` <br />