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f 1d� � Y ♦'Yf , * � • ♦ y fay' ♦ • ✓�•.• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> f SERVICE REQUEST , <br /> <Type of Bgstness or Properly FACILITY ID# SERVICE REQUEST# <br /> Z � <br /> ` f QRVNER`I OPEra�v4TOR ; <br /> - ^�•• -• CHECK if BILLINGADDRESSL] <br /> Awa !`MII�IY-N1AME _ <br /> F � <br /> StTIE ADDRESS ' <br /> IQo 1 �O�eX�n t e� man eco 53i3C� . <br /> Street Number Direction Street Name cityZi Code <br /> y HQNiE t7r MAILING ADDRE$$ (If Different frorn Slte Address) <br /> Street Number <br /> Street Name <br /> ITY STATE ZIP <br /> 1 ` PNONE1T• APN# LAND USEAPPLICATION# <br /> xkl <br /> r �w� (r. ) <br /> . � <br /> ::t-.k _ <br /> 1 . PHONE#2 Ext <br /> t O DISTRICT CA ODE <br /> B S LO TION C <br /> CONTRA TOR f SERVICE REQUE8TOR <br /> R-:"UESTOR <br /> ( , CHECK if BILLING ADDRESS <br /> v�r <br /> "w ` 17SINl=s NAME J� <br /> ... r <br /> PHONE �. <br /> l <br /> IIMEpr IVri41LING ADDRESS. FAX ' <br /> 1� 25 C�1 <br /> 17Y STATE ZIP <br /> BALING AOT( L :DGElk1ENT: 1, .the undersigned property or business owner, operator or authorized agent of same, <br /> - acknowledge that:allsite and/or project specific ENvIRONmENTAL HEALTH.DEPARTMENT hourly charges associated with this project or <br /> aetluity wili_be billedto me::oxmy:.business.as.idendfied_on-this.form <br /> ` 1 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 /> COUNTY+Ordinance Codes,"Sta_tclarrjs,.'STATE and.FEAEI;AL laws. <br /> &PiACAI�TT'S SIGNATURE Z��?' <br /> DATE: �_ <br /> -t <br /> �, �ROEF-RTY/�USINESSOWNERD <br /> OPERATOR[MANAGER IO OTHER'AUTHORIZED AGENT <br /> IfAPPLIGAIV7 is not the BIL WGPARZY Proof of authorization to sign is required Title <br /> ' _ AUT]FIORI�AT N TQ 2ELH'ASE TIVp'O10 TION When a Ircable 3 the-owner or ator of the <br /> _` PP , __ _ P_T_ �roptir located at the <br /> tY- - .. _ <br /> a e siie ark vess;Thj(Z;au raze a release of auy and.:all zesults;.geoteclinical.data_,Sr_and/or .envlronmentaUsite assessment <br /> Irl Drll tl031 tb'the SATd JOAQuIlV CtaUNTY E�NIRONMENTALHEALTH DEPARTMENT as soon as it is available and at the same.time it-is <br /> Ftoxde"tltto'�me or•�yrepi`e'seinfafve:.. ' <br /> ------ <br /> EA <br /> ERV►CEREQUESTED _. __:-- -._ _. <br /> GoINMaNTs r i <br /> t <br /> q <br /> < 4 - .. .._ ....... <br /> . .. CT <br /> SAM.}tJAaVWCOUNTY <br /> = u«f } <br /> _ ENYIROHMENTAL <br /> HEALTH DEPAR7yEN•r ' <br /> .: Z EPTEDBY u y <br /> jjr' -EMPLOYEE.#: <br /> DATE: „ y <br /> StNEIxI(? <br /> PLOYEEE#:... DATE: " <br /> ate$ervlCe Completed (If already completed) SERVICE CODE: p/E; <br /> tx =�FP,aylrtent Type.,,�,r Invoice;# .: Check# � ' <br /> �, _ �• .,. :._. ��. ........,.. Received By <br />