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SAN JOAQU)i .XOUNTY ENVIRONMENTAL HEALThI)EPARTMENT <br /> - SERVICE REQUEST <br /> Type of Businees or Property FACILITY ID# SERVICE REQUEST# <br /> ni <br /> L�QS �U'l � v o <br /> OWNER 1,QPERATOR - <br /> y.,,da CHECK If BILLINGADDRESSE] <br /> FACILITY NiititE4. <br /> SrrE ADDRESS <br /> _ aft ber DIW6 I Name Ci Zie Code <br /> c <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Nembtt Street Name <br /> STATE LP <br /> .PHONE#t --- T• APN# LAND USE APPLICATION#. <br /> i)Off Y `2,3 <br /> SOS DISTRICT LOCATION CODE <br /> ,Org SHONE#Y <br /> 4 <br /> CONTRACTOR I SERVICE REQUESTOR 0;AODRESS:REQUESTOR `,, CNECK If BILLSINESSNAN(E � \HOME Or MAILINGADDRESS25M h <br /> 'CITY - STATE zip <br /> L <br /> BILLING-'.ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> -. 'acknowledge that all site and/or project specific ENviRoNMENTAL HEALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUN <br /> ';COUNTY:Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7�3I 13 <br /> a PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O'l4TER AUTHORIZED AGENT <br /> pY�� Yv <br /> r IfAPPLICANT.is not the BILLING PARTY proof of authorization to sign is required Title <br /> c AUT$ORI�ATION TO RELEASE INI+ORMATION: When applicable,I, the owner or operator of fhe property located at the <br /> Dve stte-address hereby authorize the release of any'and all results, geotechnical data anld/or environmentaUsite assessment <br /> r_r , <br /> *— .iiif'armahou to fhe-SAN IDAQTTRa COUNTY Is�'VIrtONMENTAL HEALTH DEPARTMENT__as soon as it is available and at the same time it is ____ <br /> provrde-d4o"meormyrtpresentative. - <br /> "I'TPEDFSERVICEREQDESTED: �.{ �{- � r^.,.. t <br /> COMMENTS '•{ I Y�/31�"lC <br /> trn <br /> e <br /> EMPLOYEE to DATE: -7 <br /> DATE: <br /> ' ate$erviceCompleted (if alreadycompleted):: - - SERVICECooE: t PIE: . <br /> Amount Paid 3 �' Payment Date <br /> -71;0 lo ' <br /> Payment Type- Invoice# Check# 3.c� Received By <br /> 0. <br /> • 1 �i ,K.. t • - <br />