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SAN JOAQU*uNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of BNsiness or Property FASay 1D# SERVICE REQUEST# <br /> LAGS <br /> OWNER/ OPERATOR , <br /> CHECK If BILLING ADDRESS CI <br /> rHUME <br /> Y NAME 1 - {�n r� <br /> DDRESS l� 6 • Hamrn� UE�� �TC'CIC1l�•` 9SG�O I <br /> Street Number Direetlon street Name Cit ZipCode <br /> r MAILING ADDRESSS (If Different from Site Address) <br /> Street Name <br /> - - STATE ZIP <br /> PHONE#i W. APN# LAND USE APPLICATION# <br /> b9y2b ° ( l <br /> PHONE#Z <br /> EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING AnDRESS <br /> Y11 Wh' <br /> BUSINESS NAME t PHONE <br /> HOME or MAILING ADDRESS �5 _ FAX ' <br /> CO\Lnwem MNL <br /> -CITY STATE cp ZIP <br /> BILLING'-ACKNOWLEDGEMENT:I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> 1,also certify that I have prepared this application and that the work to be perforated will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Co des,Standards,/STATE and.FE <br /> D <br /> ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORrzEDAGENT <br /> IfAPPLLCANT is not the RmLlNGPARTY proof of authorization to sign is required Tifte <br /> AUTHORISATION TO RELEASE INFORMATION:When applicable,I, the owner or operator of the property located at the <br /> above site4address, hereby authorize the release of any and all results; geotechnical data and/or environmentaUsite assessment <br /> z� <br /> 1irfOTmatlori To'the'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn 8S It IS available-aryl at the same time It 1S <br /> provided to memmy representative. — <br /> --- -- -- - <br /> TYPE OFSERVICE REQUESTED: 2013 .COMMENTS: -- - 0 2013 . <br /> SAN JOAC UIN <br /> NEALTNRDE A TAL. <br /> ACCEPTED BY: , EMPLOYEE <br /> 8 <br /> ASSIGNEDTn; I C. �. _ 'EMPLOYEE -DATE: M <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: V <br /> Fee Amount: < ," Amount Paid J�S.oD - Payment ate D'�,j <br /> Check# SsTD Received By: <br /> Payment Type Invoice# (� I/ <br />