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SAN JOAQTJ IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST. <br />Type of Bbsiness or Prue* FACILITY FACILITY ID#Zf SERVICEREQUES <br />T# <br />SM 7000 <br />kyr 1611 N E k i b <br />7 <br />ILIrY NAME <br />STATE zip V - <br />LM413 USE APPLICATION <br />BOS DISTRICT <br />LOCATION CODE <br />CHECK IfALLLLN L <br />_G ADDRESS <br />AME i PHONE <br />WE OrFAX # <br />MAILING ADDRESS <br />6'5 <br />2-5 <br />CITYSTATE* <br />ZIP <br />-EDGENIENT.-:1,t�e undersigned -property or business owner, <br />nqc,�A QW, rat <br />WLL operator orauthorized agent of salne, <br />c. acicnomedge that .*all `site and/6": pX'oject specific aMRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project o <br />r <br />i6tivity will be billed --to me:or mybusmess..as ideiztified..on.this.form <br />, t <br />f J ha4- rqp#64-this-application and that the work. to be porform-d will be do in -accordance with all S OAQUIN <br />also ,certL <br />y. <br />UP Ii a11,1 <br />Ordinance Odd',ig, &an4gr4, -ST,a laws. <br />�TB <br />C� <br />D rE- <br />-. <br />PAOPP-BTY/.-B.usiNEssOwNrR OPERA-TOk/MA GER <br />' NA OTHER AUTHoR&ED AGENTIA_ <br />1f1.4PPL,_CxNT.is not,tFieBILLINGP.4RTY proof of authorization to sign is required Title <br />41 <br />AUTTIORIZACTI-16- Nt­ _.Q 1—RELE.- A IUN Wlien applicable;-ILt11e ovs raer or_0 J r ,f, 0 rt__ located at the <br />_Lp - V_! <br />b fth". M" ------------ <br />gy, <br />f " , . . I <br />resujts;-.ge6t6C;I�icA1.. tam or. mvironm6ntaysite iisessin it <br />GOt1rrTY-ENv-1R0NI,1ENTAAEA LTH DEPARTMENT as soon as It is available and at the same time it is <br />X <br />)I" <br />r- <br />EMPLOYETF. <br />N F1 <br />DATE: U <br />�413TI <br />PAYME <br />RECEN <br />JUL <br />DATI:.- -7 <br />RAN.InAnIIIM 9 <br />-fk <br />CEPTED BY: <br />EMPLOYETF. <br />N F1 <br />DATE: U <br />�413TI <br />RIX <br />DATI:.- -7 <br />atd Service Completed <br />(if already Completed) <br />SERVICE CODE: <br />I P I E! 2 <br />Am <br />Payment Date <br />nv61 _.P <br />CheckCheck# 5983 <br />Recelvod B <br />S <br />JNIY <br />L4 <br />ENT <br />