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r - <br /> SAN JOAQU1N('011NT'V ENVIRONMEN'I'AI, III AI:FII DEPARTMENT <br /> SERVICE REQta:ti's <br /> Type of Business or Property FACILITY ID N <br /> �� �Qlioaciv.>` RIVIC�ER�EptlN1"E8TN <br /> W O W <br /> pyyNiR I l)piRAPDIt <br /> 11\tlNt�t 1. /N(nt1 C�zc�QQti CHEcnNBILUNOAnoRFu13 <br /> F91 NME �w.� L kms �cr.�C Rlv� (`nN(AT-Er-A <br /> SREADDaEss,.,: . r Y�IT o v se r� T1vl� �S' l <br /> Street Nume.f I M.4,N'f E C-h <br /> et Ne <br /> MualGortAt>oi faDRferentfromsaeAddressl <br /> :HDW <br /> ry STATE trM Nam <br /> zip <br /> P,*E91 Ess. A. # <br /> LANG USE APPLICATION# <br /> RpENI En. <br /> 1" <br /> BOS DISTRICT LocAnoN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK N BILLING ADDRESS <br /> 87'ESs NAPE PIaNE i <br /> AtATFGf� E.. <br /> MmEorwmmADDRESS �O 32\— 11 33 <br /> y 64D \1Jo0o tNo.�f0. T�Y� FAX <br /> f I <br /> tkry M A N i E-CA STATE C LP X533 <br /> BR.i.tNG ACKNO .FM: .NT: I, the undersigned property or business owner, operator or authorized agent of same. <br /> admowledge that all site and'or project specific ENvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projec <br /> or aCM7* will be billed to me or my business as identified on this form. <br /> I also catifv that I have prepared this application and that the work to be perfonned will be done in accordance with all SAN JOAQLT\ <br /> Cot,?.7v Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APP[ICANT S SIGNATURE: DATE: o_X�\�v.",\7,-O Z <br /> wyfI <br /> I <br /> PRORTT <br /> PE '/BL'ST!SESS OWNER❑ OPERATOR/MANAGERXL OTRER AVrnORIZED AGENT❑ <br /> ifAPrt./c(A,r is not the Rut-m'O PARr proof ojaudsorization to sign it required ride <br /> _AUTNORIZADON TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release oi' any and all results, geotechnical data andor environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.IIBALTII DEIIAR'I'MENT as soon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> rYPE OF SERVICE REQUESTED; ` YM 7, <br /> TORRENTS: I Dy� I/iS D <br /> JAN 9 ?0 <br /> SAA1 JOA <br /> NEA TH DONMECyTq N7Y <br /> CCEPTED BY: EMPLOYEE M DATE: if 6r�Z NT <br /> SSIGNED TO: EMPLOYEE M DATE; <br /> ate Service CrompAd (if already completed): SERVICECODE: ' PIE: / e7,) <br /> e0 Amount: Amount Paid /5C9-OZ Payment Date ,r 2 <br /> syment Type ' Invoice# Check# 16 Recaly d By; <br /> un AemfnA .... <br /> Q�o54S 202 S <br />