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SAN JOAQUI 4%,/ )I JNTy ENVIRONMENTAL HEALTH 1,',;ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY. 10'# SERVICE REQUEST#' <br />err <br />-r <br />sl -_2 <br />/ 9 <br />OWNER I OPERAT <br />- <br />- <br />`, <br />CHECK If <br />BILLING ADDRESS <br />FACtLHY NANE <br />ui k �rteZ-e <br />SITE Moms ����71/f���r�t+�' <br />S 3Numpar <br />/ <br />D n (� ��� <br />✓n ,t <br />�/) V <br />/%]�,)✓--{�//J <br />�d <br />Strap Name <br />HOME or MAI NG ADOR SS (if Different from Site Address) <br />CStoat <br />/� <br />r <br />Cm <br />NumLar <br />gpa� Name <br />.3 lr E <br />VNATE <br />i <br />ZIP53 <br />�,j� <br />�� <br />PHONE <br />(� ) _ � <br />Ext. APN # <br />LAND USE APPLICATION # <br />i*rr: 3/c,(ag I <br />PHONE #2 <br />en. <br />. acs DIS -.?JC i. <br />t_CAT"CN BC^'c <br />CONTRACTOR/ SERVICE REOUESTOR <br />REQUESTOR n <br />TY CHECK It BILLING ADDRESS <br />BUSINESS NAME "Ni <br />U ,3-0� Exr <br />1 I <br />HOME or MAILING ADDRESS/yl FAX # <br />J IV19 ) g a <br />CITY --/,. /I I/ /ti AsTATE ZIP 12L7'7/- <br />111LLINU ALA—NOWLEDGENIENT: I, the undersimed property or business owner, operator or authorizedagent of same. <br />acknowledge that all site andior project specific EvvTRON&tENTA:. H2ALTH DEPARTJt_ENT hourly char_ses associated with this project <br />ar activity will be billed to me or me business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance .with ail SAN JOAQLTti <br />CouNTY Ordinance Coder. Standards. STATE and FEDERAL laws. <br />APPLIC.INT'S SIGNATURE: _ DATE: e // <br />PROPERTY!HUSIN-ESS OWNERQ OPERATOR!V AGER OTHER AL MOIUZED AGEVT)k A!/ <br />If.4PPLIC.iv7 is not the BauvG R <br />of <br />authorization to sign is required TC <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, aeotechmcal data and/or environrnemabsite assessment <br />�a formation to the SA..N JOAQL'IN COLIT( ENVIRo,4NIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />orovided to me or my representative. <br />TYPE OF SERVICE REDUESTED: Eem&al e ekq�ij-e <br />pel-mJ <br />err <br />-r <br />cDNMENts:REC <br />/'� <br />lJ <br />us 1 <br />EIVED <br />MAR 11 2094 <br />SAN JOAQUIN COUNTY <br />T F <br />ENVIRONME T <br />c) <br />032-4 <br />S Hl1 f <br />%3 9-V <br />.3 lr E <br />_ _ <br />i <br />5..,,Lo�t 03t/ <br />! <br />�s ✓E' �3 t�`T <br />PY4er <br />i*rr: 3/c,(ag I <br />PA-tMC-0z UKP% I/' ears+► 3tfo ► l�Q bti : � <br />E4D 48-01-025 SERVICE REQUEST =ORM <br />E,ISE <br />