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SAN JOAQUIN COCSII LWIRONMENTAL HEALTH DEPARTMENT <br /> SHO ICE REQUEST <br /> Type of Business or Properly FACILITY ID IU <br /> REQ EST# <br /> �� () <br /> OWNER/OPERATOR CHECK H BILUND ADDR[as❑ <br /> FAcLm NAME <br /> Q <br /> SITE ADDRESS S alp Qf� I,va\AI S1a c.k�on 15$OC <br /> aaM N nDa o�m P am.t rLm azip ea. <br /> HOME or MAiuNG ADDRESS of Dirierent from Site Address) <br /> 60 4 sR...t rwme.. s t w— <br /> CrTY STATE LP <br /> )ra A <br /> PHONE 01 En_ APN# LAND U SE APPLICAMNn <br /> tai+ 1a/17q- I <br /> En. BIDS DISTRICT LDCA7r NCCDE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Q v u CHECK II SLUNG ADDRE <br /> BUS14£55NAraE d E.. <br /> How or MAxims ADDRESS FAx I <br /> �CO�ly�4V 14,44_A vL w 1 1 <br /> C"Y U' G�k'a Y\ ATE ZIP <br /> BILLING ACKNOWLEDGEMENT. L the undersigned property or business owner,operator or authorimed agent of same. <br /> acknon Icdec that all site ancUor project specific E\\TRO\\iEXT:\L HEALTH DEPART\IF\T hourly Charges associated with this prCJCC, <br /> or acts its will be billed to me or my business as identified on this form. <br /> 1 also eemfy that I hale prepared this application and that the work to be performed w ill be done in accordance w ith all SA\JOAQLT\ <br /> CoL\-n Or&nance(�ndes..Srm dt ds.ST.\TE and FFDER,\L lams. <br /> APPLICANTS SIGNATURE: "G A\� DATE: 5' a() — a'O <br /> PRorExr\t Ht s Tm OR.M491, OPFJtATOR/MANAGER ❑ Ora¢R AtTnoRIZED AGENT❑ <br /> If.LR?uctc7 rs nor rhe llw%'G P4R7T proof of authorization to.sign is required rule <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable. 1.the owner or operator of the property located at the <br /> above site address. hereby authorize the release of am• and all results. geotechnical data and/or emirortrwWR�Site assessment <br /> information to the S.k\JOA"IN CtH'\T)-E\\IRowENTAL HEALTH DF.PART\tE%,7 as soon as it is assailable atld Its <br /> provided to me or my representative. R <br /> TYPE OF Sarna REctuesTer Lk%%A .r Q W Ow%xk.r ; <br /> Ccutmrts: SAN'JOA <br /> / <br /> HQU/N CO <br /> EgI H EpgRTM N� <br /> AccEPTEO BY: EMPLOYEE#: �— DATE 2 <br /> ASSIGNED TO: V 1 <br /> EMPLOYEES: DATE LI <br /> Date Service Completed (d already completed): SE110MCDOE: PIE 9/ <br /> Fee Amount: Am Cnmt Pal /Sa, L)e) Payment Date <br /> 044 <br /> Payment Type �5/� invoice# Check �Qp' 7 2,(j7 Received By: <br />