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SAN JOAQU OUNTY EWMONMENTAL HEA.LT�WPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SGS �ocac� 40 int i <br /> y OPERATOR , <br /> CHECK If BILLING ADDRESS El <br /> OWNER/ <br /> ` FAtiLITY NAME <br /> _ COQ OCs cS . <br /> s SI7 E ADDi?EsS i <br /> 2.bi�. E ck�loC� SKt1 . <br /> StreetNumher Direction Street Name City V Code <br /> HQIE or MAILING ADDRESS (If Different from Site Address) <br /> x,a Street Number <br /> Street Name <br /> TM �`CIT?f STATE ZIP <br /> I _Exr. <br /> PHONE#I APN# LAND USE APPLICATION <br /> PHONE#2„ BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REGQUESTOR <br /> n CHECK if BILLING ADJDRE <br /> Bl7SWESS.NAME PHONE /, i /Aul <br /> � �MAILING ADDRESS. FAX# <br /> �b ( 2�) �tCQ H& a <br /> "CITY; STATE ZIP <br /> BIELLNG.A.CKIYOWLEDGEMENT: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 projector <br /> activity will be,billed to me or my.business.as_identifiedon this form <br /> w = I;also'eertfy that.I have prepared;this-application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> OL7NIY Ordznance:;Codes,Standarck-STATE and.FEDERAL laws. <br /> APP .ICANT'S SIGNATURE: <br /> { l YJ`U�J1�J DATE: <br /> PROPERTY/BUSINESS OWNEREl OPERATOR/:MANAGER❑ OTHER AUTHORIZED AGENT <br /> fAPPLICAIVT.is not the BILLINGPAR7Y.proof of authorization to sign is required Title <br /> AUTIIORI. ATION TO IIELEASE INFQR]�'IATION. When applicable,.1,.the owner or operator of the property located at the <br /> above slte address hereby''authorize the release of py and all results,' geotechnical data anwor environmental/site assessment <br /> tion-la.the SAN JoAqu COUNTY ENViRoNMENTAL'HEALTH DEPARTMENT as soon as it is available and at the same.time it is <br /> rbvidedto`ITle..... a resentAtive --- - —.- -- - -- - --------- -- --- - <br /> 41 j <br /> YPEOFSERTCEREQUESTED <br /> COMMENTS - 7'7717 CEIV <br /> ,. FiE <br /> ZZ <br /> MAY 312013 <br /> SAN JOAQUIN COUNTY <br /> r ENVIROMENTAL <br /> {' HEALTH DEPARTMENT <br /> ACCEPTEDBY. EMPLOYEE#: DATE: <br /> _sAS;xIGNED TD - . <br /> EMPLOYEE#' DATE" <br /> s <br /> Date ZService�COntpleted (if already ompleted): SERVIC"CODE: PIE: Zmount Paid ate 3 jov <br /> ,,.e. <br /> p yPayment Type In Ice# . Check# s� .� Received By: <br />