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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of,Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAt:IM NME s. <br /> SITEADDRESs \��. 5 (7Glrrrnc� ) -52 <br /> StreeENumber Direction treet Name Ci Zi Code <br /> HQME or MAILING ADDRESS (If Different from Slte Address) <br /> Street Number A Street Name <br /> irY STATE zip (� 1/� <br /> JG <br /> l.d `� <br /> s PHONE#.IT APN# LAND USE APPLICATION <br /> a <br /> 'PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 4 fW_ <br /> CONTRACTOR/SERVICE REQUESTOR <br /> 1�y <br /> RE MESTOR <br /> CHECK If BILLING ADDRESS <br /> a `" v�17:SINESSsNANIE P E Exr. <br /> tv <br /> Jn <br /> ( 4' <br /> ,l�OAIIEOr AILING:ADDRESS. \ \ FAX# <br /> t ( l� <br /> CITY; l STATE ZIP <br /> a <br /> 8I1 LIhTG-AGKN WL-EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge t.. all s>te:and/or project specific ENvutol�IMENT.e,L HEALTH DEPARTMENT hourly charges associated with this project or <br /> act"—will;be billed-to me.:or my,businessasidentified_onthis form <br /> = I also certify that:Ive'.prepared=this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> GOiJNTY Ordinance Codes,Standart*,.'STATE,and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE +(� ,� , DATE: )_ �I �. <br /> PROPERTY/BUSINESSOWNF,ROPERATOR/MANAGER OTE=AumowZEDAGENT❑ <br /> IfAPnicuivris not the BILLZNGPARTY.proof of authorization to sign is required Title <br /> AIITHQRI ATI03V TO:RELEASE INFOR1kIAfiION:"When applicable;I,the owner or operator of the property located at the <br /> )iove site adt es li�=eau <br /> tho e the release of any and all results;.geotechnical data.and/or environmental/site assessment <br /> or atYon to the S AN JOAQumt•COLINTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same.time it is <br /> prop+ded to"me or rgy representaflve <br /> .r, – --- <br /> '�'� '' 3COMM�NTS <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 5 2012 <br /> SAN JOAQUIN COUNTY <br /> EWRONMENTAL <br /> *h� ACCEPTEDBY /}/t/ EMPLOYEE.#: <br /> m . <br /> SSIGNE[xId7 C�C� 9 _EA71PLoYEE-#:.: DATE: <br /> 7 12.. <br /> Date Service 10ompleted fif airdadyc6mDleteo): SERVICE CODE: PIE: C� <br /> ;tf^eeAtrtount = Amount Paid �' Payment Date <br /> _ - 1 <br /> a <br /> Pymenf Type . ^ Invoice# : Check# _ �,. Received By <br />