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• 06/09/2004 09:15 2094685 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#:. SERVICE.REQUEST,# <br /> Aar f <br /> OWNER 10 PERATOR CHECK If BI W NG AOORESS❑ <br /> FACILITY NAME /� R` , <br /> }{ Ps <br /> SITEADOR�S$ �'� � $Z+c �T��I $MCode <br /> StreeDirectloHOME Or MAILINGADDREerentfrom Site Address) <br /> Svoct Number veer Name <br /> CITY STATE ZIP <br /> EXT. APN# LAND USE APPLICATION 0 <br /> PHONE#1 <br /> 1 ) <br /> PHONE#Z EXT• BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE# ExT.2,3 28 <br /> BUSINESS NAME <br /> FAX# <br /> Home Or MAILING ADDRESS1 ' (213 ) 301-15-17 <br /> STATE C.4 ZIP Ck <br /> C" CJ1`Cz'ti-- <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 project <br /> or activity will 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 Ordinance Codes,Standards,STATE Saws <br /> APPLICANT'S SIGNATURE: % DATE: /,-)7�o Q <br /> PRUPCRTyl BUSINESS OWNER[] OPERATOR ArEN� <br /> OPERATOR/MANAGER ❑ Title <br /> If APPLICANT is not the BfLLINO PSI Tv.proof Of outhorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operrtor 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_ A <br /> TYPE OF SERVICE REQUESTED: �•S 1 K� f�� F t — ����Iv <br /> COMMENTS: V Co:" . A r t F,.Q o: Z��� <br /> 0 (~ s P, 0 0 <br /> rJID SAN 3pAC1U4 E�PC <br /> ENVI�n <br /> NE�TH pEPAT;tMENT <br /> EMPLOYEE#: C)-S ZI DA7E:.�' 1�'((1 <br /> APPROVED BY: LC U �l <br /> 1 EMPLOYEE#: e3-7� DATE: <br /> ASSIGNED TO: O nJ <br /> Date Service COrrtpleted (it already completed): <br /> SERVICE CODE:l`� PIE: <br /> Fee Amount Amount Paid �p�-1 g, v� Payment Date v � l0 <br /> �-79.60 <br /> Payment Type <br /> Invoice# Check# x.33 Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />