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JS t c <br /> SAN JO IN COUNTY ENVIRONMENTAL HEI3 DEPARTMENT <br /> SERVICE REQES'r <br /> Type Business a Property _ FACILRYID# SERVICE REQUEST# <br /> OWNE /OPERATOR <br /> CHECK if BILLING ADDRESSE] <br /> FACILITY NAME <br /> SITEADDRESS 2� CI-j2-j o <br /> Street Number Direction Street Name CityZf ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1 <br /> a Street Number_ tr tName <br /> CITY STATE Zip C) <br /> ea <br /> PHONE#I ExT• APN# LAND USE APPLICATION# <br /> ( �� 0�1�j <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAM _ n �j )� PHONE Ems' <br /> HOME Or MAILING ADDRESS FAX#A4 <br /> ) / / <br /> CITY $TATE ZIP <br /> BILLING ACKNOWL,DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> E acknowledge that all site and/or project specific ENVIRONMENTAL HEALT14 DEPARTMENT hourly charges associated with this project or <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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `�,� (�\l;t AA E: ` Cts <br /> --:„ A . <br /> Pavlova /BuSINr OWNEit•12 �__ QPEi3 TC?i3/ t1PtAlG IGTmetiIHQiUy7.FDAG£Nr_ <br /> If APPLICANT is nol the BILLING Pd RTY.proof of atttltorilation to sigh is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> informatiot4 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the salve time it is <br /> ` provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r I 72z'r—,% <br /> COMMENTS: PAYMENT <br /> RECEIVED' <br /> JAN 2 6 2012 <br /> _ If,AH JOaQiJtN courrr„ <br /> 1WRONMENTAL <br /> k APPROVED BY: EMPLOY #: (h S c7 DATE: .? I� <br /> ASSIGNED TO: ,'{t � (S E#PLOY1tE#: , DATE:. <br /> Date Service Completed (if already completed): SERviCECoDE: d I PIE: <br /> Fee Amount: ' Amount PaidPayment Date , <br /> Payment Type Invoice# Check# ; Received B <br /> EHD 4&01--025 SERVICE REQUEST FORM <br />