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;Sek1! JOA 0M CO iTY RRI i AL, HEALTH-DElt'AI <br />SERVICE REQUEST <br />7ylSe:of Businessor <br />Property <br />FACIL:ITYID # <br />. SERVICE REQUEST # <br />OWNER t OPERATOR <br />CHECK if BILLING ADDRESS O <br />FACSIfY NAME C_.. <br />SrrEAWREss <br />Street Number I Direction - <br />Street Name <br />city Zip Code <br />HOME or.MAILING ADDRESS ` (If Differeht from Site Address) <br />Street Number <br /># <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PNONE #1 EXT- <br />/A <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS I V1 <br />BUSINEss NAME i - �[_ ' . 7 En.. <br />HOME or MAILING ADDRE , _- G FAX # 1Ui <br />.�. <br />CA <br />Crrr _ STATE zIPJ c` <br />BILLING ACKNOWLEDGEMENT:: -I, the undersigned property or business owner, operator or authorized agent of same,, <br />i knowledge that all site and/or prdject specific ENvIRbNmENTAL HEALTH DEPARTMENT hourly charges associated with this project or, <br />--..._/activity_willbe.Milled.toF. nr:my.business;as-Wmili&do3L.ttzis:f�ln....; <br />I also certify that1 IIAve prbW d' thls Tieatio i' and'that•the work to be pe6o`ed vtill;be'done in'abcordance with all SAM JOAQUIN' <br />CauNTY Ordiriarice Codes,. Si4iii �arcis, ?A1 and 1�'taws. <br />APPLICANT'S SIGNATURE: - DATE: iiif`IEd n; 0. <br />PltOPKRTy / BUsM= (iW v1 R© Ot ►.Toit 111ZA1SAGER ©: On= AOT110Rizim AGENT I h to (-P� *1w0.k{'1 `I Q i <br />If.2ppyai 1iT is not the BffJ"GPAR7 :.proof of authorization to sign is required Title <br />AfTTR©RIZA'I`IQN TO`RgIlASE l<iIVIA116 'hien appticable, f, the owner or operator `of the property located at the' <br />aboiw 'site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />. information to- the SAN JoAQUIN COUNTY ENvmoNmENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br />provided to me or my representative. <br />TYPE -O SERVICE REQUESTED: RECEIVED <br />COMMENTS: MAR -82012 <br />SAN JOAOUfN COUNT( <br />ENVIRONMENTAL. <br />HEALTH DEPARTMENT <br />_ACC <br />CCEPPTf[k BY: 5 .. E66PLOYEE DATE- 3 12 <br />AssrcNt=aro Ea .aYeE #.: - DAr� . ek f t 2_ <br />..... ..r....u+ p.:�ti.. ie .rwro.•.T .....nwMr.+.... .wwwn. w- ti, ve ve +++' _ ....we ,,•••• .... <br />r... .werc t+.r, .r..v...r .r.wa..w...w ry++<w+� •. <br />...e._..n .canna.-. ,.moo ..uaw ,._. gym,. w -a r. rt.. •r . .e <br />late Soryke Completed (if ah early completed): SERVICE <br />2 <br />Fee Arnount." ti c Amount Raid 'F375; p Payment Date y <br />3 <br />Payment Type Invoice # Check # 7z -]S' Received By <br />EHD 4&fl2-02a <br />REVISED 11!1.7/2003 <br />