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SAN JOAQUIN COON'FYgM�1p��,•:NQ�/VIp�RONy� IE <br /> M ,NTAyHL HEAL'lVl 11E <br /> ) PAR'FME.NT <br /> SIE <br /> ST <br /> Type of Business Or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER!OPERATOR <br /> ' 1✓-^^ CHECK if BILLING ADDRESS® � <br /> FACILITY DAME V v r 1 <br /> SITE ADDRESS31 _ f, L LtL�}-vy, CisZ L <br /> ✓✓Street Number Direction N143i- W1 Street Name City Zio Code <br /> HOME or,'MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN„ LAND USE APPLICATION# <br /> ( 209 ► c.C"l'1-"'*`l 41 f( <br /> OACE <br /> PHONE#2 EXT. BUS DISTRICT D <br /> ( ) <br /> CONT'RAC'TOR / SERVICE REQUESTOR <br /> REQUEST CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> B BUSINESS AME ( ��) �1 J--/Z-(i(6 i <br /> HOME Or MAILING ADDRESS FAX# <br /> iSy3 <br /> (l(d W Icc aljW,4u, 14 UA., -7-3 8 ( al ) 31, <br /> CITY / I STATE,_A ZIP 9 5 V <br /> 1311,1.INLo�,"a�:'I�NL➢WLE�GEMENE': I, the undersigned property or business owner, operator or.authorized ahent of sante, <br /> acknowl-,dge that all site and/or protect Specific ENVIRONMIiNI'AI,11FAI;III DFI'ARTMENT hourly charges associated with this prgject <br /> or activi?y will be pilled to me or my business as identified on this form. <br /> 1 also ccrtily that ! have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> ('OI ('O(Ics,.Slumlarcis,STATE and FI'.DI?RAI. laws. <br /> ,tPPLIE"',4N'I''S 51GNA111RE: _ DAI�►•::__.�! <br /> EDKOPh:F"(`'I BUSINF:,SOWN I?R❑ OPERATOR/MANAGER ❑ 0-ri iz Al)"I'Iioiu . i)A(;F.N'1'❑ / <br /> lJ. PPLI(',IAI b;not the Rt1JJA1( 1';IRT)%prouj'oj'au1horizafion to si;n is required Title <br /> AII14 )RIZA"I'10N TO RELEASE INFORMA'67ION: When applicable, 1,the.owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or CIlviroltlllenial/site assessment <br /> infornlalion to the SAN JOAQUIN COUNTY liNVIRONMENTAL I-II.AI:I'I I Dlil'ARTMEN'IaS Soon as it is available and at the same time it is <br /> provider.to nle or:ny representative. �L <br /> TYPE 0 SERVICE ERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> MAP - 4 2911 <br /> ACCEPTED BY: EMPLOYEE#: ?� J DATE: <br /> r- EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� lC�<< �[' ✓�� <br /> Date Service Completed (if already completed): • SERVICE CODE: C' F 1 E: �� <br /> I <br /> I Fee Amount: Amount Paid 3 b(o _ T Payment Date 3 L <br /> Payment Type �Is Invoice# Check# 1�y� y5�pD Receive By: <br /> o SR FORM(Golden Rod) <br /> EHD 48 02 025 <br /> REVISEL'11/17/2002 6( a <br />