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SAN JOAQUI>N _.OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ICJ# SERVICE REQUEST# <br /> OX 6J' :< <br /> OWNER f OPERATOR nn <br /> Com. CHECK If BILLING AQDRESSLJ <br /> FACILITY NAME <br /> 21 1�_ Y'I'IP • <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Nurrt6or Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EAT' APN# LAND USE APPLICATION# <br /> 7d - 7 24 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDfiES3 <br /> �7 J]E)�)' <br /> BUSMESS NAME PHONE# Exr. <br /> HOME Or MAILING ADDRESS PAX# <br /> b'D (jog ) a r 3- <br /> CITYI� S STATE zip ^� <br /> 1111,LING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> abl:now lccl c that all site and/or prcjcct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to Inc or my business as identified on this form. <br /> I also cerlify that ) have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> ('I It ",i) Oreliuttace C'artie5•..Jl(mda ,A, STA I'I alld FLI)FRAL laws. <br /> AYPLWANT'SSIGNA'T'URE: L.2 L DATE: <br /> I'ltlwrl. Il 151 ON%NIM❑ t)PI•:It,N.IOlt/i••'l.%NXGE.R ❑ O"I'IIFAZALI HORIZEI)AGEN'Tld' <br /> 0.f PPI.Ic.i.v'r is not the B11,LING f':I87T,proof'nf•aulhori•atinn to sign is required Title <br /> AL 'lIORIZA,rioN TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address. hereby authori c the release of any and all results, geotechnical data andior environ T a]/site assessment <br /> roll?rnintion to the SAN JOAQUIN C'(.I:HT1' ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is ��L-the same time it is <br /> provid'-d to rine or nw representative. ��,�� �J <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V VD <br /> SNf.1 sap'Q `' v w <br /> evwgp 'PN"ATMEI t� <br /> "eo1N oe <br /> /APPR()�EO BY. L i L) Q ,,y T EMPLOYEE#: .tom! DATE: '. <br /> ASSIGNED Til: /',�`/fEMPLOYEE#: �j DATE: <br /> Date Se-v;ce Completed (if already completed): SERVICE CODE: I� P 1 E: <br /> Fee Amount- Amount Paid � ;L7Payment Date 0 cL <br /> _ 117. Q Z) T <br /> Paavmt�rt t Invoice# Check# f jQ Received By: <br /> ',� i-���_.:• SERVICEREQU <br />