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A � <br /> T-;pe of Business or Property • r:�wcu r Iu r � c, ....,,.__. .. <br /> Z, 1 ��y <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FAcum NAME 1 0p f� <br /> rSITE ADDRESS <br /> Street Number Direction Street Name Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �15 <br /> Street NumAef Street Name <br /> CITY STATE Zip <br /> PHONE#1 bcr. AM LAND# LAND USE APPLICATION <br /> Chi 011 <br /> PHONE#2 _ r% EX* BOS D[sTr/ LOCATION CODE <br /> Cqp J ��SER 10E"Q 11L•STO <br /> REQtlESTOR �', ✓ \I ��� ` y C G LAY �Gl� S� CyECKifBtWNGADDRESS❑ <br /> BUSINESS NAME 1 1 � L `-2 C � �, P►io1 # Err. <br /> HOME Or MAILING ADDRESS L� L .�Z (, FAX# OI <br /> ��? �E ) <br /> CITY <br /> STATE ZIP <br /> nes operator or authorized agent of same, ` <br /> BILLING ACKNO`VLEDGEMENT �the undersigned propertyor-business owner, ope g <br /> acknowledge that all site and/or project specific ENVIRONMENTALHF kLTfIDEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my bustness:as identified on thYs foni. <br /> I also certify that I have prepared thts application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws:' <br /> APPLICANT'S SIGNATURE: (G��� DATE: <br /> PROPERTY/BUSYNESS OwNERQ OPERATOR/ <br /> MANAGER D.' OTHER AtTnoRmzED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof ofauthorization to sign is required Trite <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the C <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative- <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> COU <br /> hN <br /> SAN J V.OEPP►LAMENT L <br /> ENVIF+ RTMENT <br /> ACCEPTS Y EMPLOYEE#: <br /> ASSIGNED TO: �-?'�� E WILOYEE#: C�� DATE:' i� <br /> Date Service Co/mCplleted (if already pteted): SERvtc/ECoDE /�� 1 P 1 E,,,? � r% <br /> -.... o <br /> Fee Amount: Amount Paid 5 �D Payment Date <br /> Payment Type invoice# heck# 3 Received By. r <br /> EH D 48-02-025 S�`RCfR(iA(Eo1dDn2oiy' <br /> REVISED 11117/2003 <br />