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SAN JOAQUI. OUNTY ENVIRONMENTAL HEALTH ',PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fac <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS El <br /> hut <br /> '.FACILITY NAME n <br /> SITE ADDRESS` \V I.J C ��� t`( � 5 mr o) cn�15 <br /> Street Number Directlon Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> I Street Number1. <br /> Street Name <br /> G(nr <br /> STATE ZIP <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> ( ) J ) �0 � <br /> EXT. BOS DISTRICT LOCATION CODE <br /> r <br /> HONE#2 <br /> .-,. Cl1i <br /> TOR UESTORMT <br /> / SERVICE RE <br /> � = <br /> CONTRACTOR/ Q <br /> � REQUESTOR CHECK if BILLING ADDRESS <br /> ' hJ PHONE Ex ' <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS ` 1`• FAX# <br /> - 2-53 L <br /> CITY STATE ZIP0�tI 20b <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 /> -. <br /> activity will be billed to me or my.business as identified on this form <br /> Lalso certify that I have Prepared this application and that the work to be performed will be done in accordance with all SAN JoAQuIN <br /> COUNTY Ordinance,Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S.SIGNATURE: 1 1 7 l �`�`l J DATE:, r�<I2� <br /> PROPERTY/BUSINESS OWNER CI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT.is not the BILLING PARTY,proof of authorization to sign is required Title <br /> -- -- -- <br /> ' AUTHORIZA.TIQIN TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property locatedat e <br /> above site address;_hereby_authOrin the release of any and all results; geotechnical data and/or environmental/site assessment <br /> _.. <br /> : 1T1foilTiation fo,the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> -- - <br /> provided to or my representative. <br /> TYPE OF SERVICE REQUESTED j - �v J i- ---------- --- - - --..— <br /> _ <br /> COMMENTS RECEIVED <br /> r ED <br /> Y JUL 15 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEDBY: �. EMPLOYEE#: Y w Y G•l DATE: <br /> A VV i 4 LW lig l <br /> --EMPLOYEE#: DATE: <br /> Y ASSIGNED T0: ii.'��t/ --EMPLOYEE rT KWLI.t <br /> SERVICE CODE: PIE: <br /> Date`Service Completed (if already completed): '�l 7,3 <br /> Amount Paid Payment Date <br /> h Fee Amount ? .l. 3 <br /> '�to Check# R r.-;.­A By: <br /> Payment Type Invoice# <br /> wu <br />