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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> - SERVICE REQUEST , <br /> Type of-Business or.Property FACILITY ID# SERVICE REQUEST# <br /> i OL. ( a ID <br /> QWNER tQPERATOR <br /> CHECK if BILLING ADDRESS El <br /> w <br /> ' FACImY NAME <br /> `-` SITE ADDRESS � I �^' <br /> ,F �a�r <br /> 1_ c� qJ <br /> Street Number Direction eet Name Ci Zi Code <br /> ' HOME or MAILING ADDRESS If Different from Site Address) <br /> +�ti.}q all Street Number Street Name <br /> rITY - STATE ZIP <br /> 4. 4 <br /> 1 . <br /> ,,PHONE APN# LAND USE APPLICATION#. <br /> (3 <br /> PWONE#2T BOS DISTRICT LOCATIO CO E <br /> - CO. TTRACTOR f SERVICE REQUESTOR <br /> - REOUESTOR <br /> � 1 1 CHECK if BILLING ADDRESS <br /> SINESS NA70E PHONET <br /> Ic u� <br /> HOME or MAILING ADDRESS FAX# <br /> n v, r 2 35 ( 2c�1) 1-6 � Z <br /> x' CITY;: STATE ZIP <br /> k <br /> nr <br /> B :LING:ACKNQWLFIl1lYIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> r acknowledge that all site and/or:pi oject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> . <br /> ache ty <br /> 11 bebilled to me or my business.as_identified_.on.this form <br /> . - also certify that.I have preparedthis-application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> GOU ITY Ordinance,Codes,Standards,'STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE . DATE: �l Cl 7 T l2 <br /> t PROPERTY✓'BUSINESSOWNERLI OPERATOR/MANAGER'❑ OTHER AUTHoiuzEDAGENT <br /> - - <br /> fAPPLICANT.is not,theBILL&GPAR7Y.proof of authorization to sign is required Tire <br /> AUTIIORLZA.TION TO RELEASE INFORMATION: When applicable,I,.the owner or operator of the property located at the <br /> _._. <br /> —--nbo�e site address, here-iy_ authorize tie release of any and all results;.geotechnical data.and/or environmental/site assessment <br /> iYrfarmation'to-tht SAN JaAQUIN COUNTY ENVIRONMENTAL'HEALTH DEPARTMENTassoon as itisavailable and at the same time it <br /> ';provded-to`me or my representative-,,_. _ _ _ _ <br /> - <br /> PEDFSWICE-REQUESTED - -- - <br /> r - -- — <br /> IWAT NT <br /> C� <br /> COMM�NTs <br /> YES OCT 1 7 2012 <br /> . � <br /> SAH JOAQUtN COUNTY <br /> ENVIRONMENTAL <br /> rxs ' H TH DEPARTMENT <br /> 0 7 r <br /> � AGCEPTEDBY 4. <br /> 5, EMPLOYEE#: L DATE: t C (• 1 Z <br /> l <br /> " #sIED To - <br /> 'EMPLOYEE#:: DATE: <br /> j I C Z <br /> Date -"Ce Completed (If•already completed): SERVICE CODE: OI P 1 E:. <br /> � _ <br /> F•ee Atrrount Amount'Paid � .1 t. Payment Date <br /> Paymetif Type -� Invoice#. Check# �� Received BM, 11/ <br /> s <br />