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09 02:27p Elite TV Contactors 12094616342 p.2 <br />—W. INA a _utt raAtVl11irAr'114IAL.LA A "JMrA1�'A1VIL+,1NI <br />I tjj SERVICE REQUEST <br />Type of Usil ess or Property <br />UCS C cSYti <br />FACILITY ID # <br />/ ?-15 <br />SERVICE REQUEST # <br />5 CDC s 3i <br />OWNERNJ J RATOR ti 4 <br />] BILLING ADDRESS <br />Gn I'JZ <br />,� \ <br />FACtIlTY NAMECY <br />�Q� <br />EMPLOYEE #:. �% 3 Z4 <br />SITE ADDRESS 1 r, 1 �` l Yi SJd <br />streetNumber; Direction <br />Street Name Cit <br />HOME or.MAILING ADDRESS ()f Different from Site Address) <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />PHONE#t <br />{ _`i <br />APN # <br />dLolO _ ti72Fl "�5 <br />LAND USE APPLICATION # <br />[PtHIONE #2 / Exr• <br />BOS DISTRICT <br />LOCATIO CODE <br />' CONTRACTOR ! SERVICE REQUESTOR <br />REQUESTOR' CHECK If BILLING ADDRESS <br />,. Ezr. <br />BUSINESS NAME l ` �� pry P N # Q ` r ! c� Q <br />cy <br />4. <br />HOME or.MAiUNG ADDRESS�<� <br />Cir - STATECJZIP 5 O V <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />" acknowledge that'all site and/or project speck 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 certifythat I have.prepared.this application and that the work to be performed will be done in accordance with all SAN IOAQUIN <br />COUNTY Ordinance Codes, Stand Zjaws.STATE and <br />APPLICANT'S SIGlIATUPX: 1 DATE: /y, r <br />�ROPERTY /BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT 1 Cl f <br />m_If,4PPLICANT .is not the Bn G P.tRTY proof of authorization to sign is requir d Title <br />• . °AUTHORIZA.TION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />'above site .address, hereby authorize the release of any and all results, geotechnical data is <br />environmentaVsite assessment <br />infoimation'to the SAN 70AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />- - �-�tov>.dtdao me or my repzesentaiive. <br />TYPEOFSERVICEREQUESTED: S oP_�7 80�=17 <br />COMMENTS:- -, <br />-7­77— <br />J�r•VIr r /U <br />' - t •• <br />JUt, 17 2009 <br />SAN JOAQU!N COUNTY <br />NNVI C3EPAR TAL <br />Fim <br />ACCEPTED BY C.t V, ter � <br />EMPLOYEE #:. �% 3 Z4 <br />DATE: <br />ASSIGNED TO: 6 A-C�_<-':. <br />EMPLOYEE #: Z&415 . <br />DATE: -7 (Z�Q <br />'Date.ServfceCompleted (if alreadycompleted ): <br />SERVICE CODE: �'� <br />PiE: <br />ZZ� <br />Fee Amount 3 1 S <br />Amount Paid v U Payment Date <br />Payment Type V11 <br />Invoice # <br />Check # <br />Received By: <br />EHD.48-02-025NMWFitJl{oleNRs�dj. <br />REVISED 11147/2003 <br />