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SAN JOAQUIN COUNTY ENviRoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PWNER/OPERATOR ; <br /> CHECK if BILLING ADDRESS <br /> FAmITYNAME , <br /> SiT'E ADDII�ss' <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS-(If Different from Site Address) <br /> w % � S Street Number Street Name <br /> �Ernit,\6�. STATE ZIP <br /> 11 I <br /> u <br /> 1 ,PHONE#1 APN# LAND USE APPLICATION# <br /> G <br /> �HONEj#�2 BOS DISTRICT LOCAl10N CODE <br /> r: CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> ` SINESS NAME r PHONE <br /> IYOME7DZOR <br /> rMAILINGAUDRESS. FAX# <br /> .2535 ) -"t� 1-b 54V2- <br /> k' CITY; STATE ZIP <br /> � Lam) <br /> b jXVG--ACRN4�LEDGE1kIENT:I, the undersigned property or business owner, operator or authorized agent of same, <br /> B <br /> acknowledge that all site and/or project specific ENvixoI�MENTAt HEALTH D> ART1 tvT hourly charges associated with this project or <br /> achvity-will be billed to me:or my:.business-.as.identified.on-this form _ <br /> I.also certify that:l have�:preparecl-this-application and that the work to be performed will be done in accordance with all SAN JoAQuIN <br /> GOT1iITY Ordinance;Codes,'Standards,.-STATE and 1)ERALlaws. <br /> _ _ <br /> AX-PLICANT'S SIGNATURE <br /> a DATE: <br /> PROPERTY I'BUSIIYESs OWNERL� OPERATOR[MANAGER❑ OTHER AuTHORizED AGENT IA tfJ2 Q__= N f <br /> ffARPLICANI.is.not.the.BH.I.&d P.4IZTY proof of authorization to sign is required Title <br /> AUTHORL ATIQN TQ RELEASE INTQRMAU0N. When applicable,I, the-,owner or operator of the property located at the <br /> ---- z_ <br /> -abeve site adtfr-ess,hereby-aufhonze t _ Bleasesny,and all results;.geotechnical data and/or .environmentallsite assessment <br /> . <br /> nTformatioii'toWSAN J6r1QuIN COUNTY ENAMONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it <br /> vi de i tome or my repiesenfative . <br /> - -- -- — <br /> 117 <br /> - <br /> 'ui <br /> ERVICBREauEsrl=.D <br /> c coraalElTs` - - - AUG -2 2012 <br /> k . Q x. <br /> :- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Y HEALTH.DEPARTMENT <br /> iz <br /> -r - <br /> 'rACCEPTEDBY L EMPLOYEE#: DATE: <br /> g <br /> S&ISSM D 1'O EMPLOYEE#::.. DATE: <br /> E)ate Service Completed (If already completed) SERVICE CODE: P/E:. <br /> a� dee Atriount \'� `'� Amount Patd /\� /� Pa ent Date y <br /> ,..T,s Tf;^'•r w + ,: _ .:.." t';�-.�� .J- ,,�✓ Imo✓ - �"` 1 r . <br /> w P�ymt3rif Type:_ Invoice#, ' Check# Received By. r <br /> Vis % <br />