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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPgR <br /> SF,RVTCF REQUEST <br /> Typs of Business or Property FACILITY IQ/ ;7SERVICE <br /> EST 162 q�i), <br /> OWNER/OPERATOR �— CHECK <br /> if$ILL <br /> FAtnm KAIAE <br /> SITE ADDRESS �5 / NIO, p 1 <br /> ;Z:77 t�- s' N"' Mal" <br /> HOME or MALUNG ADDRESS 0`Different Oven Site Address) vn � <br /> Number Shnl Naive <br /> CRY STATE Zw <br /> J <br /> PIIptEXt APN X I 00gi LAND USE A►'PLICATION A <br /> PNouE12 OOS Dt$TWT tocATroNGooc <br /> CONTRACTOR 1 SERVICE REQUESTOR G <br /> REQUESTOR CNtEcrrl[BrLLINGAflOrt>ss❑ <br /> LA-k4-y Do <br /> SustNEss NAME PHOWEI r * <br /> 12V 2 <br /> HOME or MAILING ADDRESS FAX I <br /> CfTY _ p-A C - - STATE 7 <br /> 1P 3- /, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aclmo,Aledge that all site and/or project specific ENVDLONMRiTAL HEM TH DEPAwnf Nf hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the worst to be performed will be dow in accordawe with all SAN JOAQU N <br /> COMIY Ordinance Codes,Stand-ards-�STATE <br /> I=n' FEDERAL laws. <br /> APLICANT'S SIGNATZRE: <br /> ` A <br /> PROPERTv/RVMNeas G"ER0 OPERATOR/KANAGER EJ OrxFn AvTxoruzP.D AGENT <br /> IfAPPLjcANT is not the ! 1NG P14R2L proof of a dhorkalion to sign is required Titre <br /> AXTTHORI7A'ITON TQ RELEASE , RMATiON: Waren applicable,I,the owner or operator of the property located at the <br /> above site address, hereby audwrizA the release of any and all results, geotechnical data and/or environmental/site assessment <br /> infoTT UfM to the SAN JOAQUIN CTAIXTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. Yp,/1 NT <br /> TYPE OF SERVICE RL_gIIESTEO: <br /> conrliSrTs: k�,- -4TH ),t c 7 Z <br /> `.�ATJ JCA0014, GUu`1lY <br /> FNVtiF7U'aMCN�AL- <br /> 'v' <br /> `•r`7A 1, <br /> ACCEPTED BY_ EMPLOYEE 0: DATE: <br /> ASSIGN��TO: YEE#: DATE: <br /> Data Service Completed (if already ornpleted): (� ,� i_ ME COO _ PIE_ <br /> Fee Amount: v (� Payment'Dato ( fl c L f <br /> Payment Type ✓ Invoice# Check# Received By. <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> OC\/1CCf� . irrx\n•a <br />