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r <br />Type of Business or Property <br />OWNER I OPERATOR <br />Tos C o <br />FACILn NAME TO 5 C O 3 0 ZZLI / Z (v l 11 r1 q <br />SITE ADDRESS <br />3� 5 stn.e Numhr Oinc4t <br />Mailing Address (if Different from Site Address) <br />2b00 Crow (1rny—or <br />� <br />CITY 9, 6 n <br />Sir <br />PHONE 91 W. <br />(Ci Z'71- Zrd 0 L <br />PHONE#2 <br />SERVICE REQUEST <br />x000 b qq"� <br />7 r2 R (-`i SUVA H4" <br />1+ y oC) - <br />AP N # <br />• <br />SERy10E„REQUE T <br />BILLING PARTY JK <br />13Lv 0I <br />T— Suits <br />STATE Cp ZIP Q I+C J <br />0 2 <br />LAND USE APPLICATION # l J <br />SOS DI57RICT LOCATION CODE — <br />CONTRACTOR I SERVICE REOUESTOR <br />BILLING PARTY ❑ <br />REQUESTOR <br />Lc'Rt F2E5F+bur2 <br />PHONE # Exr' <br />BUSINESS NAME .---n• R 1 A tAG L -e C:N N( I: V, O N ryt ET1T R L A <br />Fax # # <br />MAILING ADDRESS u r bar L r 8 �� a- tO `t -Z -q <br />STATE n ZIP Cl r SOS <br />crrr �ur C <br />bGn i� v <br />BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator oo`a utho�ued�ageenntt billed to ma army bus acknowledge <br />that <br />all Site <br />on this fonn.� sped4 <br />Pueuc HEALTH SERVICES ENVIRoNmENTAL HEALTH DIVISION hourly charges associated with this project cavity <br />I also cerdfy that I have prepared this application and that the work to be performed vn11 he done n accordance with tip SAN JOAOUIN COUNTY Ordinance Codes. Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />Tpst?D /YI K�rG.,� DATE: .r I � - O 1 <br />PROPERTYIBUSINESS OWNER ❑ OPERATOR IM4NAGER ❑ QhEtAUTHORIZED AGF1l r` Title <br />It APaLcxgT is not the fpr, PAarr. P� ct authorsodon to sign b nW r+d <br />AUTHORIZATION TO RELEASE INFORMATION: When applicabie, I, the owner or operator of the property located at the above site address, hereby authorize the release Of <br />HEALTH SERwcEs E^or RONxru HEA' <br />any and all results, geotechnical data andior ewronmentallsite assessment Information to the SAN JOAOUIN COUNTY PUBLIC UH DIVISION as soon <br />as it is available and at the same time it is provided to me or my representabve. <br />TYPE OFSERYICERFQUESTED: REPa12 _ FHkT5 �NbT�FL�f��Onl <br />PAYMENTCOMMENTS: RECEIVE D <br />SAN.JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />DATE. <br />APPROVED BY: <br />,1. 5 DATE: j — C <br />ASSIGNED TO: EetPLOYEE ». <br />j� �• P IE - <br />_C <br />E. <br />Date Service Completed ('if already completed): <br />SERVICE CODE:. , -. '� 0 <br />Fee Amount <br />Amount Paid ✓ Payment Date (� <br />Check # Received <br />Payment Type f Invoice# g -1 <br />