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SAN JOAt COUNTY ENVIRONMENTAL HEALOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA on0� l 3 0 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> PAOLIT NAME <br /> SITE ADDRESS" <br /> q15' e' <br /> r <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING AbDRESS (If Different from Site Address) <br /> nu Street Number StreetName <br /> - �r'ITY ...,• ,_ .: ._ ,... STATE ZIP <br /> �;' ZPHONE#1 <br /> T APN# LAND USE APPLICATION# <br /> ( ) b I <br /> r © C) <br /> PHONE#2 T BIDS DISTRICT LOCATION CODE <br /> (� ) <br /> ICA <br /> <_ <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Y. <br /> CHECK If BILLING ADDRESS <br /> $L�SINESS NAME \ r ` PHONE �I EXT• <br /> i�OmgEbr MAILING ADDRESS. FAX _ <br /> -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/orproject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activlty-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 hi accordance with all SAN JOAQUIN <br /> GOUNTY Ordinance Codes,Standards,`SSTTA�TyE�.a�nd :EDD�F `llaw�s. <br /> A'PPLICANT'S SIGNATURE: p[ 11 1 1 l C 11tJ DATE: (�["f.`� L(�,��J . <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTmR A=oRIzm AGENT <br /> fAPPUcAN,T is not,the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORISATION TORELEASE 1NFORMATTt3Nc When applicable,T, the.owner or operator of the property located at the <br /> bone slfe athiress hereb "au-. onze tie_release of an an. — __- <br /> _ s,_ 3' =_ . y d all results,'.geotechnical Bata and/or environmental/site assessment <br /> in#Ormation to the SAN JOr\QUM COUNTY ENVIRONMENTAL'HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> �rnvld6, to"me or my representative <br /> _... <br /> EOFERvicE REcmESTED -- - -- - <br /> xr. Cl <br /> 'x' COMM�NT;i <br /> PAYMENT <br /> RECEIVE[) <br /> - - <br /> OCT 17 2"013 <br /> SAN JOAQUIN COUN <br /> V a� <br /> �r` ACCEPTEDBY t, " EMPLOYEE#: IAL <br /> DATE�E�� 4 A TM T <br /> 4 sti <br /> rte; <br /> .=EMPLOYEE#:: DATE: <br /> F mate Service�Compieted (if already completed): SERVICE CODEC P 1 E: 2'3© <br /> {Fee Amount } _Amount Paid 7DD Payment Date / �7 <br /> - <br /> +Pymenf Type Invoice#, Check# S 7�?� Received By: <br />