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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART41ENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACHM ID SERVICE iREUUEST€ <br /> OWNER I OPERATOR ,� lA� aCECX itwgz L <br /> a <br /> 1.f1\ lv\of Gr <br /> FAmm NAME 2YTGS�1 I�IKL u (gyp ' ''y <br /> SITEADDRESS ILI()O O (� f,W� UU Swat l••P �a+-�'�. <br /> / Cada <br /> S> t "m a so-esl uam. <br /> HOME or MA&M ADDRESS (1r Different from Site Address) <br /> Smneel Nu•�er -Ka,*s <br /> Cm STATE Zip <br /> PHONE81 Ea. APNA LAND USE APMCATID'r� <br /> ter o kap i 03i <br /> PRturE>1? �• - LOCJQmn Cone <br /> p CONTRACTOR /SERVICE REQUESTO R <br /> REQUESTOR Lel\et t�rlo CA Y\ 1 ; / <br /> - • CWMIlaLLMAMPESS <br /> Er <br /> BusmEssNAA1E PH <br /> Q.e�resh lOcl�Xat01 C <br /> 2�`1 riSA► — <br /> HOME orMAnneDADORES <br /> t Sv^. L� IAat € ) <br /> 1 O°I O 7 <br /> CITY ) .,e STATE G. A 2P qS L'3 <br /> BILLING ACKNOWILEDGEMENT: I, the undersigned property or business owner, operator Or authorized agent of same, <br /> acknowledge that all site and"or project specific ENVIRON\1E\'TAL HEALTH DEPARl14E17 hourly charges zssp6ated with ibis project <br /> or activity will be billed to me or my business as identified on this form. ' <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SATE IOAom <br /> COUNTY Ordinance Codec,Standards.STATE and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: DATt: -f 19L?oz.� <br /> PROPERTY/BLsi.Nm OWNER O►ERA a/'AlA\ACLn0 OTHER AtmioRtzen,Acaxr❑ <br /> !f APPTIGA7 is not rhe B1W,,VG PART]:proof of authorization to sCgn is"uired T:Nr <br /> AUTHORIZATION TO RELEASE INFORMATION: X%%cn applicable,1,the owner or operator of the property located at the <br /> above site address, hereby authorise the release of.any and all results, geotechnical data and'or encironmrnta4:ite assnrn <br /> information to the SAN 1OAQUIN COUNTY DA1R0N%tEVTAL HEALTH DEPARTIw0\7 as soon as it is available and et ej cane time'r,is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED' <br /> Caal�Nrs. SANS <br /> NFgCTH Q pM MUVTy <br /> At:cEPTE013Y: rq ey r,t EMPLOYEE$: OAT£ �( <br /> ASSIGNEDTO: Yl " EMPLOYEE C: U <br /> tate Service ComPlated (if already cornpletad): SEmYce Cow. 01r, PIE: d 2_ <br /> Fee Amou lS Amount Pa a b ,?.o Pa"V11 Date <br /> Paymant Type invoice A Ch,"** S R '6I*• <br /> R <br /> REVISED I)117 <br /> RrAM GC � . <br /> pl?0'5JI3"1 SR FOM <br />