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4 <br /> SAN.T®AQIJIlN C®iJ1VTi'ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ SERVICE REQUEST <br /> _ <br /> Type of Bdsiness.or Property FACILITY IQ# SERVICE REQUEST# <br /> " 5 ► `.: N � <br /> e� <br /> s UtN�IER/OPERATOR - <br /> r CHECK if BILLINGADDRESS El <br /> tm E~ACItd1Y NAS E <br /> . L� <br /> SITE ADDRiSS �Cln2_ <br /> Street'Number Direction Street Name City Zin Code <br /> 4 HQME Or MAILING ADDRESS.(!f different from Site Address] <br /> Street Number Street Name <br /> — �'iiT�` -•yy-q STATE /� ZIP <br /> 1. G <br /> PHONE#1 ..Err. APN# LAND USE APPLICATION <br /> " PONE <br /> H #2. BOS DISTRICT LOCATION CODE <br /> _ . ..CON,TRACTOR/.SERVICE REQUESTOR <br /> 'REQUESTAR <br /> CHECK if BILLING ADDRESS <br /> s Bty51NE33 NAME} t PHONE# _ EXT' <br /> HOMEor MAiuNG ADDRESS. FAX# <br /> ` C(TY' STATE ZIP C� /\ <br /> X <br /> B]tI INO r�.OKNQFt?I.7EllOENIENfi:I,:the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/6k#6ject specific ENvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will:be billed to me::oxmy:_bnsiness-as ldantltied_ori-flus form _ <br /> f' .= I also cerfi y that I Piave prepared,this-application and that the work to be performed will be done in accordance with all SAN JoAQUiN <br /> COUNTY Ordinance Codes,standards,.-STAT E and.FBA9I Elaws. <br /> A 'PLIGANT1SIGNATTJ E <br /> 3- _ <br /> 1?ATE. 4 <br /> 'p8 \ <br /> Ii,OBERTX'/•BUSINESS OWNE)i:Q OPERATOR/:MANAGER 0. OTHER AUTHORIZED AGENT lV�'�����i N'e J «.A isnottheBILZINGPARTY proof of authorization to sign is required Title <br /> _ — <br /> ,E AHTffQRI ;ATIOIV TO RELEASE WORI�'IA—ffQN:Wlieii apphcatile;Z, the_owner or o era of-the]property located at the <br /> _ _ _ _ _ _ _. <br /> �bo�%e site a dress heir authanzt ere ease of an and all results,' geotechnical.data_ant3/or'.environmental/site assessment <br /> r; �' Y <br /> _Y ilrfnrmation to the SAN.JDi�QUTN COiJNTY:ENVIRONMENTAT HEALTH DEPA.RTiv1ENT.as soon as it available and at the same.time it.is <br /> pro�+de to me or my representative .-' - <br /> ,,_ ERVICE REQUESTED <br /> coMMeN�s7_77777-7-- AUG <br /> ®2 2012 <br /> a< COAl <br /> ENVIRONMENTAUNTY <br /> 3 SAN JOAQUIN CO <br /> HEALTFT[7EPARTNlE , <br /> AGCEPTEDBY `_.-, DATE' <br /> EMPLOYEE#' <br /> r SS) NEL7_l0 'EIGIPL-DYEE GATE' <br /> Date Service Carnpleted (If aiready completed) SERVICE CODE: <br /> * aee Amount '•Amount Paid <br /> . :: - r �yment®ate <br /> Pa <br /> :t <br /> aymenf Type Invoice# Check# Received By. Z ,. <br />