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SAN JOAQCOUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> � P_ <br /> r FACILITY NAME <br /> SITE ADDRESS 41 "GV 2_65 <br /> M3 Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> } <br /> Street Number Street Name <br /> 1'- CITY STATE ZIP <br /> ExT• APN# LAND USE APPLICATION# <br /> "eP ONE#Z -ExT. BUS DISTRICT LOCATION CODE <br /> lik <br /> s* ( � <br /> N al v CONTRACTOR/ SERVICE REQUESTOR <br /> 7` REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> m <br /> r` BUSINESS NAME i PHONE ExT• <br /> " 3�1 <br /> HOME or MAILING ADDRESS FAX# <br /> 2-5 3 -� ( 2�>> GtCQ 1-C� tftl <br /> CITY< STATE ZIP C� <br /> BILLING..:ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> M. 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 identifiedon this form <br /> also-certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> LINTY Ordinance Codes,Standards,STATE and REDERAL laws. <br /> .. <br /> APPI IGAN 'S SIGNATURE: DATE: — <br /> PROPERTY/BUSINESS O WNERO OPERATOR[MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 9APPLICANT.is not,the BILLING PARTY,proof of authorization to sign is required 1x Title <br /> ti AUTHORIZATION TO RELEASE INFORMATION When applicable,:I;the.owner or operator of the property located at the <br /> abee� i}e address hereby authorize the Blease of any and all results;.geotechnical data and/or environmentaUsite assessment <br /> �k 3�1T1 O tIOn t�le SAN JOAQT7IN COONTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is <br /> �- �roidse to me or my representative <br /> _ _.. <br /> r TYPE DSERVICE REQUESTEDP' Wbwa �- <br /> WOIBMI:NTS ` <br /> > <br /> FOCT 032013 <br /> rix <br /> yt yE <br /> F 'k SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> Ira'' <br /> ACCEPTED BY 11. EMPLOYEE#: DATE: <br /> loll <br /> 113 <br /> }#SSIGNRzTO ., _EMPLOYEE#: DATE: <br /> Date Service <br /> PIE: <br /> E:eZ O g <br /> k9��nE77 <br /> FeeAmount 3 Amount Paid 3 ( Payment Date (O >? )3 <br /> rI *PymentInvoice# Check# ���J',� C� Received By <br />