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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTOEPARTMENl <br /> SERVICE RE, QIUEST . <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> rw�r„�r •ww e. CHECK if if BILLING.ADDRESSE] <br /> FA'C LMNA'ME <br /> Slt ADDS ss <br /> ` 'a l t-ane <br /> ri <br /> -street Number Direction tree Name Citv Zip Code _ <br /> HOME Or MAILING AwRas (if Different from Site Address) <br /> Sfreet Number Street Name <br /> ` ITYSTATE ZIP <br /> .. <br /> j <br /> PHONE#t - APN# LAND USE APPLICATION#: <br /> PHONE2 FXT• BOS DISTRICT LOCATION CODE <br /> 00 (f, <br /> { - CONTRACTOR/ SERVICE REQUESTOR. <br /> ,r <br /> .,.�ar- rCEC1UESTOR ..: . <br /> CHECK If BILLING ADDRESZ <br /> F j •' "� <br /> ' BtISWI$S NAME �r)1L1\`YV�� /`yid ►Y�1t(+ PHiON(E9 L"-xr. . <br /> �yll FAx# <br /> rl(7ME' r MAILING ADDRESu <br /> WPMx <br /> �c. CITY STATE (0 In ZIP 20 <br /> BIIiI.ING.AOKI�I(;R4 LF }GEMJENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all kte.arid/' project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> actlty willbe billed to me or my.husiness.as-identified.on.:this form <br /> alsocertify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> GOI7NTY Ordznance:Codeg,Standa <br /> rds,.'STATE and F1 AEItAT laws. <br /> AI'PI,IIGANT'S SIGNATURE TRATE: _ <br /> OOPERTok IMnNAPROERTY/'$DSINESS OWNERGER'0 OTHER Auvao zEDAGENT t <br /> -T Pniai V�.is not.th,e BILLINGPARTY proaf of rtuthorizatiun.to sign is required Title <br /> AUTHORIZATION TO RELEA-SE I NFORMA-T'ION 'When apphcable;_I,the owner oir operator of the <br /> _pr6p located at the <br /> - - _ <br /> = above �Ite address � - - —ry --- - -- — -..- ------- <br /> ere�y au or zeta_release of any-and.all results;.beotacluucal:data.an or .environmentallsite assessment <br /> II olnlation rto the SAN JOAQi7IN C6bNTY ENVIRONMENTALHEALTH DEPARTMENT-as soon as itis available and at the sax�e time it is <br /> providet3 tq.me or rriy representative q <br /> - <br /> COMNJENTS <br /> ' S . <br /> Fp04 <br /> gA�� <br /> - FH <br /> �ACCEPTEDBY EMPLOYCC#: DATE: 1 <br /> _ <br /> ° Z3 <br /> NED TA 4 EIVIPr:6YEE#:_ - DATE: <br /> (�. .� <br /> Date-Serutce Completed {if already completed): SERVICE CODE: PIES a (`i <br /> dee Amount '� Amount Pai �j?s`bb Payment Date 7 <br /> -, <br /> :Paymenf Type Invoice# Check# Rereived.B <br /> dt1 '1•—T-f M a A + 1 1 1 4 R 1 4 t••... <br /> Frr t -"'.1' '�'{'� . °� 11 .j 1 d y1 l tl t1 .tt.. .t^.Ar • _°.i 11 4j f 1' ,h ° t1 .•ijIf -_ <br />