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S..AN JOACOUNTY ENVIRONMENTAL HEALAIIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Buslness or.Property FACILITY ID# SERVICE REQUEST# <br /> -79 <br /> iry U p l 3 S ( aj <br /> ;• /OPERATOR ; <br /> CHECK if BILLING.ADDRESS <br /> 0M'f FACIL1TY NAME <br /> Abbk�ss _ = . ' <br /> e Street Number Direction Street Name Cit Zip Code <br /> PME Or MAILING AbDRESS (If Different from Site Address) <br /> rr•��.. �.., :a, Street Number Street Name <br /> STATE ZIP <br /> I}t HONE1 - •' 'APN# - LAND USE APPLICATION# <br /> x L rP�lONE#2' rxr. <br /> BOS DISTRICT LOCATION CODE <br /> x� � <br /> (9 <br /> tt34- <br /> CONTRACTOR/SEk2V CE REQUESTOR <br /> �a-�" kREC�UESTOR <br /> a CHECK If BILLING AJJID <br /> 1 PHONE <br /> B1Si Css,Ni4ME 1 <br /> N <br /> on <br /> F�OM�1Dr MAILING ADDRESS. FAX# <br /> r�3 L�iITY` \ STATE (6 1�bib <br /> 11P �C <br /> � `` V <br /> B, E �NG, 1OKNt 4�LF EMENT: I, .the iuldarsigned property or business owner, operator or authorized agent of same, <br /> r. acidi'WIC dge that all Site and/or project specific ENVIRONMENTAL.HEALTH DEPARTMENT hourly charges associated with this project or <br /> r' activity will i e billed-to me:ormy busmess_as identified..on this form _- <br /> ',_ I also cerci y'that I have.prepared,this-application and that the work to be performed will be done in*accordance with all SAN JOAQUIN <br /> CoT TNS Y Ordinance Codes,Standgrds,`STATE and.FEDERAL laws. <br /> a <br /> c APPEICANT'S SIGNATURE �_ r- _ DATE: <br /> PR�Is>✓RTYI'BUSINESSOWNERC::.t ?OPERATZ)R/MANAGER I.� OTHER'AUTnoP.I.ZEDAGENT <br /> XfAPPrkANT.is not.theE1LL&GPARi'x proof of authorization to sign is required Title <br /> AtZTIORIATIQN T07F2ELEASE TNFC?RMATIt3N When apphcable�:I,ttie owner or_operafor of fhepraperty located at the <br /> �o�e site address hereau oµ z release„of any;and all xesults,:,geotechnical data an3/ox .environmentaUsite assessment <br /> in#tirniation t the SAN JOr'..QuIN COUNTX ENwRoNytEN AL HEALTH D13PARTMENT-as soon as it is available and at the same time it is <br /> T� - — — -- <br /> prb�ideti tom r my representntive <br /> PAYMENT,c, YPEXIF,ERV ff EQ1yESTED <br /> — _-- - -- — <br /> ECE <br /> e3 MW <br /> H� [ � f,1 SEP 11 2013 <br /> �,a 4, <br /> _ <br /> HEALTH; t ari TAL <br /> E RTMEI� . <br /> v <br /> D PA <br /> A; I�CCEPTEDBY EMPLOYEI"#: DATE: ' <br /> S Ss1�NED TQ _ <br /> I�Pr�oYer_#{.. I tG 2 Z ...Dare•. <br /> ,Rfl hUate 6ervlt;e Completed (If alreadycompleted) SERVICE CODE: /p P/E: Z J?D 8 <br /> tiFee Amdtint <br /> Paid Payment Date <br /> +P yinen#Type (nvpi.ce# Check# s(o S Received.By: . <br /> r 1 � et.++�d 4. f {• ' � .« <br /> '"SK. ;'�4 "1 1 • / e+ e r K ' �°'4. <br /> �4. .e:.�!'�`. i r 1.. , • .+ 1 w ." / � s r .. .tick .. .ice z,. i M a1., a+ 1/ + r .' + r. `i1 a'��+_ <br />