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Oec-01-03P.02 <br /> 12: 10P <br /> ��, �.• «�� <br /> Z1.131 vay� ENVIRONNMENTAL OTH PAuE 01 <br /> SAN JOAQUIN COUNTY ENVIRONWNTAL HEALTH UEPARTIMEN-1 <br /> Type t)t i3usiness o►Property F,A'>Kt '� � 5ERY10E REQUEST# <br /> oc, 36%;2-g� <br /> QWNE /.OPERATOR f! 0�7 / � CHECK if IIIIIA-IM4 AQQ1j1K§A� <br /> FAearry NAME r3 p v M1 <br /> $frEAflDAES� -tre�tN ben �.e11e OJ"CI��Ut Nam- <br /> HOME Or MAILING AWRE4 tff Different from Site Address) /)jAi �5-T <br /> d .: _ Str..t CX <br /> Na <br /> _ _..... <br /> CITY ,t JC=�.�Q�. sTA,r,� Z,v ,F . <br /> PHONe Rt �y r APN ii <br /> LAND USE A1�pLICATION f1 <br /> PHO , f EM, UOS DISTRICT LOCATION CODE <br /> CONTRACTOR t SERVICE REQUESTOR n <br /> REgUESTOR Gp>sCK tt BILLfNd ADR1Lgg1 <br /> _ -5GrIN ( zb-► - <br /> PH <br /> BusiNE5S NAME <br /> NOMEa MArum,;ADDRESS FAX <br /> STATE <br /> E <br /> NO <br /> A-[CK?q� E66EMENX: I, the undersiped property or business owner, opernter yr authorized age of same, <br /> Scknowled;e that all sile and/or project specific ENVIRONMENTAr_HEALTH DEv <br /> PARTMF T hourly 4?larges associated with tins}:tejp.ct OT <br /> acrivit„-ill br,billed t+O me or Rny business as identif ed on this fo= <br /> also cert 6,That I have prepared ihis ap ' ation and that the worZn <br /> crfarnu:d will be done in accordance with sill <br /> SRN JOAQUN <br /> CouN Y Ordinance Coder,Stanciarals.S ATL d FE ER�L laves. n 0 <br /> APPLTCANT'S SIGNATURE: �� '(. DATE: <br /> rAtrn401U7%D AGENT QrkorERTY/BUSINESSOWNLRC� OPERA NAGETire <br /> lf,�pP1JC,f ris not the ({AARTY onf autbori.,dtien ro sign is required <br /> AL"THORIZA ON Ta REMA�E IN�O1tMAInJON_s wren applicable,2,the owner or operator of the property/seated at the <br /> above site address, hereby authorize the release Of any pnd all xeaults. $eotecwcal data and/or envirownentaUSitea essesSmtDt <br /> information to the SAN JOAQUIN COUNTY E11MRONMFNTAL WALTH DL-PART,4F_NT as soon.as it is available 2nd at the SO=time it is <br /> provided to me or my representative. <br /> TYPTr OF SERYfCE REQVEgTEt7'. j� Z, %�G>" C� •/��.✓'� ��� <br /> �oMM�s� � <br /> D <br /> SPN 30 ao MSR M�N� <br /> ���N MEPP <br /> =11y <br /> EMPI.OVTe V. �? �� E: f 2- �AGGEI'tj L i tDn1E: jl3 <br /> ASSIGNj10 j4r 11,1 e <br /> Data Service Completed (11 already complotsdl• <br /> SERVICE CODE' U P I E• � 11 6, <br /> Fee Amajint: l C Amount Paid Cb a1 qPayment D2te <br /> . _.. <br /> Invoice p Check# 1 Otocalvad Sy <br /> f�ayment'type 77 <br /> - SR FORM(Golden Rod) <br /> EHO 4"2.A25 <br /> REvr5t:fl 151171 OM <br />