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SAN JAAQUIN(,COUNTY LNYaRONMENTAL HEALTH DEPA12TMENT
<br /> SERVICE RE QUI
<br /> Type of Business or Properly :, FAQILIiY:ID#, ` ::SERVICE REQUEST i{.
<br /> OWNER/.OPEFIAT.OR. •. ; •'. . . ,. ..
<br /> . U � �rCC , 'CHECK If61LLIN0ADORE.43CI.
<br /> FAatlIYNAMEIOuL 77 . [ O.
<br /> SRE ADDRESS :. �' S TF��+.'.: ! '
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<br /> STATE.',.: . . :..,:(:.; P••r.: .:
<br /> CITY . C'.(�!cl��a?+-�...'. ..' .': .. '• ,. .. , :,: '•: i. .; •. .. ;i✓b-.' ; .. . :.$?.37,(5, ' . : •. ,.
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<br /> 12'x`79 99 .
<br /> CONTRACTOR/SERVICE REQUESTOR
<br /> REQUESTOR (rIuCNECNIFBN11NOADDREssEl
<br /> ''BUSINESa NAME,.,
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<br /> TATE ':ZIP
<br /> BILLING CXNOWLEDGEMEN1 Vibe undersigned,properly Ar.business,owaeq operator or authorized agent of saint,
<br /> acknowledge.tl>atell site,aild/or project specificENv1RONMEmTAL HEALTH DEPARTMBNThoprly Charges associated with q!t$pr ect or,
<br /> activity wil l be.bi.ed tome ox tny:bNsiness ae,idenhfied an ihiS form
<br /> ;I also certify that i have prepared this application and that the work to be perforn►ed will be done,an accordance,with all SAN J0 IN
<br /> t:OUNTY Or�dindnpe.Codes SrdndocAr'' TA E and FE6 �
<br /> APPLICANT'S SXGNATUXi/E DwTe
<br /> PltoraRTY/;BU41NESaUwNtSRLJ OPERATOR/MANAGRR:!?, OTRSRAi'MiORrzEDAGrNTE
<br /> ':fAPPLrCATl7Lr nORthe BlLtrNGP.tRfl'�rOOjOJdullrOrt�mflOJr r0 SigIt.lSl'.CAMlred:i Tule
<br /> AUTIIO� TION'TO RE LEASE'INFORN7ATION When applicable,1"the. or,opprator Dfahe property,lOcated at ilte;,
<br /> above stte,lnddress, :hereby nuthorize.ahe,releaso of eny ud sll.`rgsulte, geotechnical dsta in or eAvironmeniallsite:msesampntG
<br /> infonnahoii to-the SAN.76AQUIN.`CDikrii LT1yIRONMENTALHEALTH.DEPARTMENT as,sOon.Aa 3t is avatlabl4 and at the same ti
<br /> meat is
<br /> progided-to me or,my representarive.
<br /> TYPEDF.SERMEREOUESTED: .,';.' Li�S T .`
<br /> COMMENTS::::•. .. U.I+Sr-::i.y. .,,.,.`o•yS
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<br /> ACCEPTED BY: EMPLOYt;EiY: �ZJDATE.: �
<br /> AsSIDNEn It EEO:.::x$.17 DATE:.'..: '•?L FJ
<br /> Date Service Completed :(If already completed): SENVICECOUE: ' PJE:.'2.3 be'•.
<br /> Fee Amount: Amount Paid
<br /> Poymont Type � .�fT ` Invoice# �1E1 ok If r Received By:. C,Lb
<br /> l fibRIG17790 'nnl/II ' 11 ' IS/ZI ' II ) nn? Q7 nlnr (NnUll Aima
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