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SAN JOAQUIOUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST - <br /> Type of Busines o Prope \ FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPE O .� ^ - <br /> 'f//� CHECK If BILLING ADDRESS <br /> FACILITY NAME _. -._. <br /> kkaS <br /> h- <br /> SIX4QRE$Soladi //)/_�^Street Number Direction t ame I✓ode <br /> HOME Or M L G ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONEfft ET. APN# LAND USE APPLICATION# <br /> --- <br /> PHONEExT• BOS DIS CT LOCATION CODE <br /> (:X) 99 -17 <br /> CONTRACTOR/ SERVICE REQUESTOR----------- ---_---- <br /> REQUESTOR <br /> �/( p ccnmnct V 1 CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME - PHONEI <br /> J <br /> HOME Or MAILING ADDRES AX <br /> ( q) 40 O <br /> CIN STATE ZIP - - - - <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed to me or fldardy, <br /> ss as identified on this form <br /> I also certify that I have preparlicanon and that the work to be performed will be done in accordance with all SAxI7o�QUlx <br /> COUNTY Ordinance Codes,StaATE and FEDE / / (A <br /> APPLICANT'S SIGNATURE (��r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIl,Ei/AGENTall" 1 Ile; <br /> If APPL7CANTisnotthe BlLLfNGPARTY proof of authorization to sign is required Title - -- <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. /l r <br /> TYPE OF SERVICE REQUESTED: (/L.$ r- P( <br /> COMMENTS: <br /> OFA , Fp <br /> sq�Jo Z00 <br /> h FNt'jR DUN B <br /> E9CTy�OFryi <br /> p�F�Cp�� <br /> M <br /> ACCEPTED BY: ©L-lam"CA 9-hf- EMPLOYEE#: © DATE: f2 <br /> ASSIGNED TO:- V(-AJ ,�.L EMPLOYEE#: ff'-:;" t DATE: ( Z [.([0 00 <br /> Date Service Completed (if already completed): SERVICE CODE: (et C' -.-- FLEc_..2�- H.-�._—_ <br /> Fee Amount: 31 S Amount Paid 315 Payment Date 12141 L) <br /> Payment Type ✓ Invoice# Check# 35 a5 Received ey <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 - - k <br />