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SAN JOAQ* COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />VA 4i <br />OWNER/ OPERATOR �l <br />CHECK If BILLINGADDRESS <br />IPA ( <br />Fat amr NAME1 i Z�1cl 1 �Y - a % 3i� CXR <br />ADDRESS :I <br />Street Number Direction Street Name Cit Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />* ti` Street Number <br />Street Name <br />'.ITY - STATE ZIP <br />1 PHONE #1T APN # / LAND USE APPLICATION #+ <br />;c <br />c L _ � 031 02 / <br />PHONE #2BOS DISTRICT LOCATION CODE <br />r - _ <br />CONTRACTOR / SERVICE REQUESTOR <br />sN REQUESTOR CHECK if BILLING ADDRESS <br />uAU <br />4- <br />$1y51NESS NAMEr1,\ PHONE T <br />DOME Of MAILING ADDRESS FAX # <br />2-535 <br />CITY STATE ZIP n <br />Wb <br />BII LING.-ACKNOWLMGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />ackn g <br />ll site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />- actio tylWill be billed to me or my.business.as-identified on this form <br />I,also certify that.I have:prepared`this-application and that the work to be performed will be done in accordance with all SAN JoAQUIN <br />COUNTY Qrdinance. Codes, Standards, STATE and. FBAE$AL laws. q <br />APPLICANT'S SIGNATURE: l_��_)� ly DATE• _/�01_��� �I• <br />• t �( <br />PROPERTY / BUSINESS OWNER OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENTn���� <br />If APPLrCANT is not the BILLING PARTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the ,owner or operator of the property located at the <br />_ - - - -= -= - <br />above slte address, hereby autllonze the release of any and all results; . geotechnical data an or environmental/site assessment <br />ia(o) lfition:to the SAN JOAQ�COUNTY ENVIRONMENTALHEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovded to me or m re resentative <br />k TYPE UI SERVECEREtIUESTED - . - -� - -- <br />f ...... TEL ._ _. _. •. -- <br />CoMMeNTsj .8 <br />t - <br />+.> _ SANLjO <br />2 <br />013. <br />A �rINNT <br />Y <br />EVHEANOgTMTFAFT <br />:. 3 <br />i k ryAGCEPTEDBY7 EMPLOYEE #: DATE: L} ($ 13, <br />-- <br />s <br />9SIGNE D 70 �::..EIGIPLOYEE#7 Ca L Pr i DATE: <br />Date Z&vlceornpleted. (if.alreatiy°completed):SERVICE CODE: P / E: Z 3� <br />,ee Airlount '�.J Amount Paid Payment Date <br />3�5- 11K <br />13 <br />,,WPyment Type - Invoice # : Check # _Gj Received By: <br />