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SAN JOAQUI_ "OUNTY ENVIRONMENTAL HEALTU JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C;S Stcil �(1 3 � 5,rtvl <br /> ,:OWNER/OPERATOR <br /> CHECK if BILLING ADORES <br /> FAciLrrY NAME <br /> SITE 4DDRESS' �/,fQ 2 I2 <br /> Street Number Direction U 1 e Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY, STATE ZIP <br /> PHONE#I ExT' APN# LAND USE APPLICATION# <br /> a,r � <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> - CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i CHECK If BILLING ADDRESS <br /> t � BUSINESS NAME PHONE# ExT. <br /> ( MA <br /> 14OME_or MAILING ADDRESS FAX# <br /> 7 <br /> 2-5 <br /> x ' CITY STATE 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 projector <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 JOAQUIN <br /> GoUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> � APPLICANT'S SIGNATURE: �I�l DATE: � - 24- 13 <br /> PROPERTY/BUSINESS O WNER D OPERATOR/MANAGER D OTHER AUTHORIZED AGENT ��Q� _ <br /> ffAPPLICANT.is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,.1, the owner or operator of the property located at the <br /> above ite address, _hereby-_authorize the release of any and all results;.geotechnical dafa angor environmental/site assessment <br /> :- <br /> information to`the SAN JOAQUIN 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 /> - - <br /> -TYPE-OFFSERVICEREQUESTED— -- <br /> -_--FEFF <br /> —_ ---- — - — .— <br /> r . <br /> Y COMMENTS <br /> _ AN 2 4 2M3 <br /> v-r ':ACCEPTED BY." EMPLOYEE#: PERn�'il �DrI�E:V ti <br /> J0SIGNED.TO EMPLOYEE#: DATE: <br /> a <br /> Date Service Completed. (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount Amount Paid �� Payme-n ate a <br /> <Payment hype: Invoice# Ch ck#: Re eived By: <br /> .;,�� ��� ' ? .^ . , ;" ''��z'�1, . ',-+ �. .�. � � �, •�,k' t`. <br />