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02/24/2005 13:47 2094683 FIFTH FLOOR. • PAGE 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVTCE REQUMT <br /> Type of Business or Property ff �j nFAC�1ryLiTY ID# SERACE REQUEST I1 <br /> d`e �1- E?- KCS Ili 1 <br /> OWNER 1 OPERATOR <br /> } CHECK irt81LUNC ADDRESS <br /> FAciury NAuE IV <br /> 2 rVV',-5 -76 <br /> We AQCREss 6 <br /> Strvmt Number Dlr*cSw Hama © C 21D Code <br /> Horse or MAILNG ADDrtFss (if Pifterent from Site Address) <br /> sbeiit Number Stree!Namr <br /> Crry STATS zip <br /> PMK#1 APN# LAND USE APPLICATION# <br /> PHONED ill Dir. DO$015TrctoT LOCATiON CGDE <br /> { 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> Cxewc rc gltt.N0 ADDREss <br /> ec>sa,€ss N,M ta�;t <br /> P <br /> HOME or 1VC>c p: CSS 751; Uv'�— t� 4� FAxti <br /> �Cffy STATE C� ZIP � 7 <br /> IMC_-ACXN0WLEUGRi4IENT' I,the=k igreAl property or business owner,operator or autJ orked.went of same, <br /> aekz:,owledge that all site andlor project specifie EMTWNMZWAL HEALTH DEPART VONT hourly nhsrgos associated with this project <br /> or activity Will be billed to me or my business as identified on dus form. <br /> I a;zo coA4 diAt I have prepared this application and doL the work to be performed will be done in acscorrdancc with all SAN ioAQvuv <br /> CMNTY Orn►inrrnce C:�,x,S#auTard�ATE&ndERat,laws.APPLICANT'S SIGNATURE: �� DATE: <br /> PR4ft1YlBL45SS4ET�SQW] t® APER,kTQRIlkI LTIPr ❑ C*ESA Tlc^AGVY! <br /> I.jAPPLICAM is of rhe ByLU1yGP.tttTP.preof OftWhOrkXiOX W suet is regUired Title <br /> AY1THaRTMION TO RELEAM 111MORkL:T3M:'i b,-n aMikable,I,the owner or operator of the property located at the <br /> above Bite address, hem-by v+Aorize the mlea� of any and all restA+ts, geotecWcai datr a n&/.r=,iro=cn%Ysite asses=== <br /> information to the SAN JOAQUIN COUNTY E gMRO2MENTAL HEALTH DEPARTWNT as soon as it is available and at the same time it is <br /> pfovided to me or my represenmitive. <br /> TYPE OF SEMXI i Pi E t ESTED: <br /> carauleM: ��c�h..t�-✓�;cam.-1 � ( 1 V�� t e�.���--��Z� fir'�(lj-c-,e�"nev�`�p. �E EGA <br /> 2 g zoos <br /> Aa�IN cOUNN <br /> ACOM, Sr. C_I U EN®LOYEE#: 2r DATE: 2 Zd'f '' E �RONMENTAt- <br /> AsstoN,To: ���4 vQ Etat€ter�#: e3�`t DATEZ 2� OSREA N DEPARTMEt�t <br /> Date 5erfte Completed (if already completed): SEWre CME: 9 P/I- <br /> Fe4i Arrsatrn7 ' Amount paidPayment Date -:;,L�75 <br /> Payment Type Invoice a Cheek 0 Received By: <br /> EMD4"2-025 SR FORM(Golden Rod) <br /> REVISED 91l17t m <br /> . R,v <br />