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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> • SERVICE REQUEST 7C.177 <br /> Type of •orpftmwly FACILE y 10 f BERVM REQUEST i <br /> PAYMENT ��g <br /> OWWR/OPERATOR cy+Ecrc H <br /> LAW E <br /> 4 <br /> FACIM WifE n <br /> SIT EADDRESS rL$ uJ r of E_�_ /� uENTHR Lrr✓.0-E'J <br /> Imam -coy <br /> AWRM W Mfferw*from sea"*"a) y���o�n� <br /> Crry rPo <br /> t ;3 h2 l�. ! /'1 <br /> a. <br /> STA ZIP 9 s2-- <br /> i <br /> EAPN/ LA�m Use APPucArm ti <br /> P p <br /> 4o'7-ZG o-07 <br /> ��� gpq DmTtucT LocATart CooE <br /> ( 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> tREouEs Crtlerc w � <br /> Busa+ESS WAME !FAX <br /> # 3 _ a exr A <br /> HomE or MAm wG ADDREss z� f.a c6 r SG . 91 33`i OTZ-S4 <br /> Cm LD s01) STATE Zw ciS2 5F0 <br /> I, the undersigned Property or business owner,operator or authorized agent of some, <br /> acknowledge that all site and/or project spocific E NVIRoNmENTAL HEALTH DPYARTMENT hourly charges associated with this project or <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 perforated will be done in accordance with all SAN JOAQUIN <br /> COU'rm Ordinance Coder,Standard.*,STATE and FEDERAL laws. <br /> APP14CANT'S 91GNATURE-. "o DATE: <br /> Paorrxtr/$tlaarassOwrora� OrRaA"MmAnwcra 13 OTHM AUTHOW"A,=-)W <br /> r - ,If"pucmT is not thegaj,&O,['AM proof of authOI to stars is required Ttrrs <br /> :When applicable,I,the owner or operator of the Property located at the <br /> TO RELEMeotechnical data and/or environmental/site sssessn7nt <br /> above site address, hereby authorize the release of any and all results, g <br /> 8tformation to the SAN JOAQtJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> . TYPE OF SdtVtCE REtXtESTED: L t W�r � C.R)A-S%�_ LO nI S�(,L-r�477 0 <br /> COMM": C)6S*4VA77on1 a>� Sot,_ r040r-rc IE rE KCt4v.47To J J D AIeT <br /> ,S-Gthc RS C�k•a 6£ "SF-4 r.J "'EGC O F $'��>DiQ(� C <br /> p u AJ77 L I NS,QEG7a r2 t S O u r <br /> '�£6-f J SICCA V"E ^) cat <br /> Via• .5,�i� Id ar <br /> ACCEPTEit O(, VE t e EuPt oYEE D 3 2/'�9 DATE !4 OS <br /> Ea1PLOYEE/: DATE: <br /> A3W-NED TO: E,Q/N - ' <br /> Dab Sarvlce Comptated (w atr ady eompi$%W: <br /> StxncE CODE: O(o! P E: �2-o Z <br /> FN ;,;_ . _3 0c7 Aptpunt PaW 3D PayrnaM b Dat Jc <br /> $ trhoctc tY By. <br /> Paynirrtt ` <br /> EH646*2 A,:- <br /> REVISED i 1/171�2DD� <br />