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-'., . -•�,• •u'. .ana,laGAl.lrillEYAt(1MLI'N'f <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# <br /> SERVICE REQUEST# <br /> �� � 3�to s2 Cu5gays <br /> OWNER/OaFtrllznq <br /> CHECK If BILLING ADDRESS <br /> FAGIII[Y NAME <br /> SITE ADDRESS � `� � <br /> SUeet Number Directs Street Name \ v <br /> HOME Of MAILING ADDRESS (If Different from Site Address) Ry <br /> CITY 5 umber Street Name <br /> $TATE Zip <br /> PHONE#1 APN# <br /> ( ) <br /> �3�-otLAND USE APPLICATION# <br /> o-�s <br /> PHONE# En. <br /> ( ) BOS DISTRICT ` LocAAnoN CODE <br /> J J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO ,p . <br /> �'ZS`1vS _ �VL� CHECK if BILLING ADDRESS <br /> BUSINESS NAME C: <br /> HOME or MAILING ADDRESS tj � , \ \�� �y� � F,A.,�clryl� t' � <br /> CITY ,�\J - ' F^" D �F —�� <br /> STATE 1, ZIP jo <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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL law <br /> APPLICANT'S SIGNA } q( fy�, , n h I O D <br /> DATE: <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑. On&AUTHORIZED AGENT tom QOC L <br /> - - - IjAPaLTcdNT is not the B¢LwcPaK7r proof of authorization to sign is required r/rte <br /> Ddty <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> -. - [11 <br /> OF SERVICE REQUESTED: — j`� <br /> ENTS: <br /> PAYME <br /> RECEIVED <br /> 1AN 2 a 2010 <br /> SANEW RONME TMNI LENT <br /> PTED BY: �(_t U'&( TH DOMEMPLOYEE#: �j Z� DATE:NED TO: EMPLOYEE M �J ` /-J �T -� DATE: � L- l�Ser!! aCompleted (lf (ready completed): SERVICE CODE: ((7P1E:mount• 3 Amount Paid D� Payment Date <br /> Payment 2g l <br /> Ym TYPe�y- In y. <br /> # Check# eceive B <br /> EHD 48-02-025 D <br /> REVISED 11/17/2003 4�11WM"M;. $ j,'. <br />