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SAN JOAQUIN COUNTY ENMONMENTAL HEALTH AC, PA,RTMENT - - <br />SERVICE REQUEST <br />Type of Business or. Property FACILITY ID # SERVICE REQUEST # _ <br />owNat OPERA - <br />a 1 OR 4 <br />CHECK If BILLING ADDRESS E] I I <br />a' FACII ITY NAME <br />/lye n C,z <br />" $/iI Dp1 ESS streetNum6er pir 0a I -C -Ci) J <br />' k <br />I *¶kms actio 51ree Name Cit ZI Code <br />"Ii E er MAILING+4 6D E$5 ifDIfferentfrom SiteAddress <br />[ <br />Street Number Street Name <br />rr <br />STATE ZIP <br />f <br />t'ps, h HONE#t ..ExT. APN # LAND USE APPLICATION#. <br />I � <br />S 0 <br />15 aNE#2 i_xi. $O5 [)[STRICTr LacAnaN CODE <br />tib <br />C ON T, RA.CTfJR 1 SE12WCE.REQ UESTOR <br />`f REQUESTOR <br />4 r CHECK if BILLING AOOR65SEA j <br />t' BI}StN� %IAME.ta , PHONE# <br />' <br />�t Nome prMAluirio ADpREsS FAx# <br />• <br />��IrI, 'CIT Yr STATE ZIP ' <br />I <br />," I„ BIF,ZJ1Y;GNIjGE1ki�iVT: I, the undexsigned property or business owner, operator or authorized agent of same, <br />rf. aci _0.Wledge ;that allsite 4016r p0ject speck ENVIRONMENTAL HEALTH DEPARTMRNT hourly charges associated with this project or <br />y , y s-ide>ltified..on.this form <br />acttvrt will be billed:ty me-o�m :;h>tsiness a <br />I•also certify that Y have prepared 'this'application and that the work to be performed will be done in accordance with all SAN JoAQUIN <br />GourvrY Orcii►tance Codes, Staradgrds,`STAT.g and FWERALlaws. <br />f APr ,fCV,T'S SIGNATiTI C DA*rz: <br />t I'a0 <br />MANAG 51NE35 wNER 1 OPERdiirtiit�. <br />liri(II3U ER LJ - QrHER'AUTiiOIiIZGENr <br />EDAI <br />a : I -APPLICfiNl.is not the $ILLdNGpARTY proof of authorization to sign is regWreri Title <br />._ <br />UT TQ" L]EASIl Q TION When ttppl cabi-- ':the owz<er or operator ©f the ro�erty located at the Y_ <br />-�bo�re��:�e "der ss; her authorrze tie reast* e'dny and al rasa ts; •.geote-ciiuictata ,an%x .envirarnnentaiTte assessinent� <br />�--. �.--. BNT.as soon as it is available and at the same.tiTne itis <br />�m�tzon��,the SAID! JOAQUI�f, CDUriITY �IVYIC((3NMBNTAT. . <br />3� DEP,ART�YI <br />rr"��"`�,'�t��ld��o."th�bt,m re r�§eutsfive <br />}�PEi3F5EKVtGEI%15vypS I V: <br />... _ s <br />. s <br />RECEIVED <br />- <br />,l <br />;RIO a k JUP�.3 0 2013 <br />A F I .n .. ,. .... .. ., . . <br />COUNTY <br />SAN QAQW4 fi ��-'� ,••LIQ U • , <br />E <br />F�+IRonn�NrAt <br />• . H ALi H Def-�AFdTMENi' <br />r <br />�'bG6 i b�iY n EIrIIk6 EE#: 1 <br />Pt s3k <! n <br />DATES <br />MPLOYEE.# Di4TE:' <br />'� t� otatl+ce Completed (i atreai�y+complP00 I <br />y ate <br />SERV OD 8 PIE:. <br />7 L��6 <br />iCE C <br />i�•�� ran e�l°�t�iottnt ` `� .�.:, ...,: ;.�,': � A � <br />l?a ment D <br />mount�Paid � 7 3p <br />Check # y/ Received. BY. <br />on, i ypc� invple� # a <br />- <br />� <br />� �raxxus°a+*sa� <br />