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SAN JOAQZ OUNTY ENVIRONMENTAL REALEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00 <br /> T �Avc> <br /> OWNER/OPERATOR <br /> __ T mita :,ate ., q�.:�.t; .-.. :.i L ..,r. „ •.:_ CHECK if BILLING.ADDRESS❑ <br /> 'F`A'CILITY NA'IGIE �;> ., `I 1 <br /> } 4 � <br /> SITE ADDRESS ;C <br /> Street Number Direction Street Name <br /> CiZi Code <br /> MQME Or MAILING AbDRESS (If Different from Site Address) <br /> u Y': Street Number Street Name <br /> — "CITY STATE ZIP <br /> a <br /> I PHONE#1 <br /> Err. <br /> n APN# / LAND USE APPLICATION <br /> - T• BOS DISTRICT LOCATION CODE <br /> ( . ) oaks. <br /> LL <br /> CONTRACTOR/SERVICE REQUESTOR <br /> ry ". <br /> x REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> � = ; <br /> @ $15SINESS NAIVE PHONE EXT. <br /> 'C1 (2 �Cc l—Co 3�1 <br /> I TOME Or IVl/11LING AD DRESS �� FAX# <br /> 2-5 t k i CIM` STATE ZIP <br /> BILLING ACKN(1WL,EDGElYIENT:I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 /> __a COUNTY <br /> #!w; e.Codes,St04 ards,'STATE and.FEAER9L laws. <br /> APPLICANT'S SIGNATURE: �' Y DATE: r �1 21 <br /> PROPERTY/BUSINESS OWNER <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ,pl�� � <br /> 4PPMCANT.is not the BILLINGPARTY•proof of authorization to sign is required Title <br /> A-U.MOBZ&T,IUN TO RELEASE INFQRMATTON: When applicable,:I, the:owner or operator of the property located at the <br /> - -= --- <br /> above id, address, hereby authorize the release of any and all results;.geotechnical data and/or environmenW/site assessment <br /> ` inftsimation to the SAN 7OAQUIN COi1NTY ENVIRONMENTAL HEAT TH DEPARTMENT as soon as it is available and at the same.time it is <br /> prsvide`d to ne or my representative <br /> frjkFW- <br /> A YPE��ERVICEREQUESTED � � T =c- c -��:�• - -- ---ia - -r,I - — ----_ <br /> _COMMENTS Cc N <br /> �V <br /> T Sq �p ZQf4 <br /> N <br /> 7 <br /> a, � � TIyDFM Fj�TgU/y <br /> ' AGCEPTEDBY .: <br /> iky EMPLOYEE#: DATE: <br /> r S&I�aNEp -f <br /> _EMPLOYEE#:. DATE: <br /> Date Service Completed (If already co pleted): SeevlcE CODE: P/E:. o� <br /> VIM <br /> Amount <br /> ,W Amount Paid Pa ent Date <br /> f Payment Type I Invoice# Check# S8 Received By: <br />