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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE RE,QUEST <br /> Type of Business ar Property <br /> FACILITY ID# <br /> SERVICE REQUEST# <br /> S E Flk vb 1�31� S2 6�1Sp� <br /> QkV(iER'1 OPERATOR <br /> CHECKIf BILLING.ADDRESSO <br /> PACaetY <br /> " f�EADDRE3S 3 I(1t� Rd <br /> 5^, y�E �U` <br /> Street Numhar Oirecfian Stmet Name _ Tfu q 5t E <br /> . <br /> E•Dr MAILING ADDRESS (If Different from Site Address) cl. -- Zip code <br /> Simet Number St ee Name <br /> xt�$"rM+• - - STATE ZIP <br /> `ch HONE�f1 - fir• AP # --- LAND USE APPLICATION#. <br /> , <br /> #Z:?. � _ <br /> E ' BOS DISTRICT <br /> .` 5 LOCATON CODE <br /> CONTRACTOR f SERVICE' REQUESTOR <br /> � y x Pi 1 LlulY'lj - CHECK IfBILLINCAbbREM <br /> PHO W. <br /> g7,ar�vtFgILMG AD DRESS . FAX <br /> ` <br /> STATE <br /> " �l1 <br /> a1CIfl9O iEDi=hMT. I, the undersigned property or business owner, operator or authorized agent of same, <br /> m'18dg0't}>1tM d#slote'add/or project specific ENVIliONMENTIAL HEALTH DEPARTMENT hourly charges associated with this project of <br /> 3' 3oUvxi}s wtll be bille _me oc my business asidentified..on-this form <br /> ._.;. .. . <br /> talso cerftfy tliBtThaverprepareri flan-application and that the work to be performrd will be done in accordance with all SAN JOAQUIN <br /> "^--- ��Q[dI>tance CasJ,�ts�tsnd¢rds.STATS and FBDeRAL laws. <br /> j,1 -4fY <br /> Y\ <br /> t; �PLIC2111� S.1 _lfiaT[1iF <br /> ry•T....; ..,..a .,nA�M y DATE: <br /> 1 of o <br /> 1-uQRrrsm�ss 6wrt sa�7 3,a•c•` OPERGMi/MANAGM[I <br /> Oxnlen AuxxoruzEn AGENT \' <br /> aq -� .�p,PLrC9�V7'is not the RmuNGP.IRpro'ofofauthorizgtion to sign is required � Title <br /> +d4 E fl '1fil RE1VIfO <br /> - - in <br /> When a p716ktile,Tithe owner or Ofierator of the_p o erty' located at the <br /> P _ <br /> a .,„ else of any'an f-alts, geotecTiatoal data -- on udn site assessmeatt <br /> S53N JDA tlra'CY DBPAR EEN�tIRONMENTALHEALM NT.as soon as.itis=available and.at the same time it is <br /> IT�PrDvfda ta.YhLrO ti}S3ropi$� {e _ '_— TM ---— _—_ <br /> xWill- <br /> 1/pr <br /> N <br /> - gq JUN 1 7 2014 <br /> N JpgQW <br /> #f R t ME l�H DOMEgU Ty <br /> EPgRTjN� <br /> x EPTEDBI� I <br /> * 4:- kA vNrEMPIAYEr# DArE: 1 <br /> .SSIGNED TO: .. <br /> TV _..DATE - <br /> =k LaYear:OVEEYt: <br /> (te,¢e}tmice'Co <br /> mPleted '(if atready^completed): <br /> K, �iJ••J-<- SERVICE CODE: f a PIEJ2{ <br /> _ 1 : Z <br /> 1 ati4`i': , Yr7 lAm_ ount Pai-- 5_b� payment Date 1p . <br /> r . • e# Check#' ' <br /> .:.`..: . , JS1 7 7 Roceived.By. <br /> � � lnvpir. <br />