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•..r. ' <br /> SAN JOAQCOUNTY ENVIRONMENTAL REALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bpsiness or.property FACILITY Ip# SERVICE REQUEST# <br /> 00 8 <br /> OWNER/OPERATOR <br /> CHECK If$ILLING•ADDRESS� <br /> ypµ{g <br /> -MAbILmr NAME ' <br /> s, <br /> ,,SITE* DDRESs `I .'� tsJ E.ST L PE ifi q 5z 1v <br /> M F Street Number Direction Street Name Cit Zi Code <br /> HpMi Or MAILING i4UDRESS.(if Different from Site Address) - <br /> pi 1. <br /> Street Number StreetName <br /> ?'xTYx STATE ZIP <br /> t PHONe#t Err. <br /> APN# LAND USE APPLICATION#- <br /> ExT BOS DISTRICT LOCATION CODE <br /> eL <br /> xw{T <br /> 'fl .:. <br /> } t <br /> -< = CONTRACTOR/SERVICE REQUESTOR <br /> 1�� �RE(�UESTOR <br /> r <br /> CHECK If BILLING ADDRESS <br /> rM` BtYSINESS plAN1E t PHONE ExT• " <br /> HOME or MAILING ADDRESS. FAX# <br /> 9 <br /> gl��c SITS! STATE ZIP <br /> BI> LING-AG`KNWVMEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aclaiowledge that; 9'site"and/ofproject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> _ <br /> activity, will'be billed to me or my.business.as identified on.this form - - <br /> Y,also•certify that.I have prepared=this=application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> s' and.FE1�Ei&AL laws. <br /> ODUNTY Ordinance Cod s, tandards,STATE <br /> { <br /> APPLICANT'S SIGNATURE -Y'11(YYl �4��1 _ DATE: O[` 114�L12) <br /> L <br /> PROPERTY/-BUSINESSOWNER� OPERATOR/MANAGER G� OTHER'AUTHORizEDAGENT IA <br /> r If APPLICAIV�`is not the BILLING PARTY proof of authorization to sign is required Tire <br /> AUTIIORIATIQN TO RELEASE TNFORMTION When_apphcable_I,the owner or operator of the property located at the <br /> — - - _. ... <br /> a$oV a addtess, herei�y authiirize a r--ease of any and all results,'.geotechnical data an or environmental/site assessment <br /> " F :. <br /> Y iiiformationto.the SAN JOAQUII�I COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> �itpide1 to"me or xny reprrenttive <br /> { <br /> YP OF SfiRVICEREQUESTED 4.1 <br /> COINwRECEIVFu <br /> l. <br /> OCT 172013 <br /> & �* SAN JOAQUIN COON <br /> ' EN HIROMENTAL <br /> DEPARTME <br /> ALr <br /> k�/�Ct;EPTED�Y; EMPLOYEE.#: DATE: <br /> rISa1NEP TO.-. <br /> EMPLOYEE#: DATE: <br /> .. <br /> Date S+ rvice.'Completed {If already compieted) SERVICE CODE: (� P/E:. Z �$ <br /> Y° <br /> x <br /> ' e qmn in .Amount Pal` ... Payment Date <br /> ��x��t^F�,1�ymenf Type invoice# : Check# � 7� Received By: <br />