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1 }• 1 t / t; 1-)t i ' 1{4 • �1� • ."�.1%_T �Y fi•t�IA + ! 1• 1 1 1 t is i f'•�i y�Y _ A-� • 1> fl r 1 t 1 1 i <br />f f 1 NI {:k + f • • ! , 1 1 r „t- Yj}11/ F.■f. .f I Y ! } 1 <br />7 <br />SAN JO'AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />- 1 SERVICE REQUEST <br />Type of Basine>s or Property FACILITY ID # SERVICE REQUEST # <br />5 _ ��3 <br />r QWNER/OPERATOR i 1 <br />i CHECK if BILLING ADDRESS <br />1-A`DILITY NAME �}�� <br />SITE ADDRESS' � ,, bCCK 1Cl(1 kt <br />E _ _ <br />Streef Number Direction Rtreet Name Cites— Zi Code <br />HOME or MAILING AbDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE#I -EXT APN# LAND IlSEAPPLICATION# <br />PHONE#T <br />EXT. BO.`i DISTRICT fECATION COD_ <br />t = _ CONTRACTOR / SERVICE REQUESTOR <br />-REQUEJTOR ` CHECK if BILLING ADDRESS <br />BUSINESS NAME r PHONE EXT• . <br />Yl '�.�-C�. t—Co 3�i <br />w NOME Or MAILING AD. -DRESS FAX # <br />2-5 <br />3`-t'2 <br />CITY : STATE ZIP C� <br />`V1 \ V <br />STFI.iNG--:1CKNt`?VIYF�llGE1kIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />aclmgwledge that -all site ancYor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector <br />activity will;be billed to me:ormy.business.as-identified-on this form, <br />Ta lso certify that.I have.prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />_ COL1i11 Y �rcitnance. Codes, Standards, STATE and FEDERALlaws. <br />n APPLICANT'SGNATf1RE: _ <br />tt---••�t ATE: <br />PROi'ERTY I BUSINESS O ERED <br />i -� OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT I T K ,► )� ��`J.Ji 1 V1� �( <br />I'4PPLiCANa'.is not the BILLING PARTY proof of authorization to sign is required —` a� Title <br />-- <br />AUT IORIZATION_TO RELEASE INFQEDIA'ION When applicable, -1 the owner or operator of the property located at the <br />above site adds ess, hereby authorize a he release` of any :and all results,-. geotechnical data and/or environmental/site assessment <br />Information iC the SAN JOA COUNTY ENVIRONMENTAL' HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />T _ _ — - - <br />------------------- ----- <br />provi eli to me or my reps esentative PAYMENT <br />��YPEOF SERGICE REQltE8TED <br />coMMErrrs FEB 0 7 201 <br />r <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH flEPARTMENT <br />rte--- <br />z� ACCEPTEDBY EMPLOYEE #: DATE: <br />SSICaNED TO _ -EMPLOYEE #:: DATE: <br />Date Setvi ce'Completed. (if already completed . SERVICE CODE: PIE: <br />24it <br />P Amount Amount Paid c� Ra ent ate <br />x W 375: 7 <br />?. <br />Payment Type Invoice # Check #–� Received By: <br />