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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />- SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />fauk <br />Z <br />OWNER/ OPERATOR _ <br />t CHECK if BILLING ADDRESS ❑ <br />FAtimy NAME <br />cclmcivI� <br />SITE ADDRESS' 2,( Sff- STUc�tc� 152 5 <br />Street Number Direction Street Name city Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 E)cT• APN # LAND USE APPLICATION # <br />,PHONE #2 , Ex <br />T Jr6S,DiSICT LOCATION CODE <br />( ). <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME i PHONE# ExT• <br />ROME or MAILING ADDRESSFAX # <br />-6 <br />2-5 <br />CITY: STATE ZIP <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 tome ormy business as identified on this form <br />Lalso certify that:I have -prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />4� APPLICANT'S SIGNATURE - may`> DATE: _ 01 <br />".,l'0�2,c�b�sC1� <br />_PROPERTY / BUSINESS O WNER D OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPuCANT.is not.theBLLLINGPARTY. proof of authorization to sign is required Title <br />AUTIiOR%ZATION TO RELEASE INFORMATION: When applicable, I,ahe owner or operator of the property located at the <br />- - <br />-. - - - — ---- - - -- .. <br />above -site address _hereby, authorize the release of any and all results; . geotechnical data and/or environmentaUsite assessment <br />information.,t the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />EMPLOYEE #: <br />ivmount - Hmount rasa j�5 1191 <br />nestType_ Invoice # Check # <br />OCT 19 2012 <br />� >;gH,oA—cun+ cauttTr <br />E)MRpNMEHTAL <br />Vtr,ALTH DEPARTWENT <br />SERVICE CODE: l <br />Payment Date <br />DATE: <br />DATE: <br />P/E: -2 z �� <br />Received By: �'f <br />