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SAN JOAQ COUNTY ENVIRONMENTAL HEALEPARTMENT <br /> SERVICE REQUEST <br /> 3 Y Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COGS �7Lo �eoo�g��� <br /> QI(II(•tER I^OPERATOR - CHECK if BILLINGAODRESSO <br /> a V, <br /> -FACILITY NAME - <br /> SITE ADDRESS .' .�.haY w^ / l li p icq a , <br /> Strael Number Dlrectlon lA )(�' <br /> !etName1 'C�t' l �Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Sree Name <br /> `CITY .. STATE ZIP <br /> P N 1 T• APN# LAND USEAPPMCATWN#. <br /> M4 ��): 62 - I' <br /> mz "PHONE#2 -'EXT• - BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> `h 'REQUESTOR - <br /> (G� -1., CHECK If BILLING ADDRESS <br /> r- I 1 l 1 <br /> ' -BUSINESS NAME \ t ` PHONE _ I b�—Lo C�nraci ��� '• <br /> yn FAX#HOME or MAILING ADDRESS <br /> M, 2535 <br /> 'CITY - STATE Qp ZIP <br /> M <br /> 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENThourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> T also certify that I have;preparedthis application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY dOrdinance Coes,Standards,STATE and FEDERALlaws. <br /> _. V <br /> APPLICANT'S SIGNATURE: �(/����y / <br /> a�lll ll_Y�Jl 11�J DATE:�o <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER❑ OTHERAUTHoRrzEDAGENT 14 <br /> IfAPPLICANT is not the BILLINGPIR proof of authorization to sign is required Title <br /> A 01k1ZATION TO RELEASE INNORICRATION: When applicable, I, the owner or operator of the property located at the <br /> — = — <br /> =•->- sbeve slte address hereby authorize the•to ease of any and all results, geotechnical data and/or environmentallsite assessment <br /> •vtformahon to the-$AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> prbytded to me or my representative. <br /> 'F Mgt <br /> b <br /> 4,-O <br /> t PEFSERVICE REQUESTED: ,f-� 7. <br /> 4 �CCMMENTS: ElV,P1. ® <br /> NOV <br /> ' j2 <br /> 2013 <br /> KK I SAN dOAQtIIH C <br /> HEAOUIYTY <br /> LrH DEP.E L. <br /> s, <br /> Tc CEPTED BY: YEE.M DATE: 11 17 <br /> EMPLO (T <br /> •EMPL-OYEE#:.:. 1. . oZ l _DATE: <br /> ate Service Completed (if already completed): - SERVICE CODE: PIE: <br /> .23ad' <br /> 4e eFee Amount: l lr• Arnount Pai 37 �Zj Payment Date <br /> 'Payment Type Invoice# Check# 5_7157 Received By: <br />