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. 10/14/2004 16:09- " 2094683433 FIFTH FLOOR PAGE 02 <br /> .— .••�K�• ..v.,i•a . lulvvirctilvMe:tr1AL RI.EALT�EPARTIVIENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> n \ F FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> FACACY NAME 1'r CHECK If BLLLINOADDREss r_,f <br /> SrtEADnRFss _1 <br /> Street Nvmaer DHe ion <br /> HOME OrMAILINGADDRESs (If Different from Site Address) CI ii Code <br /> CITY Stied Numae. Deee Na <br /> STATE zip <br /> PHONE#1 ar <br /> t ) APN# LAND USE APPLICATION# <br /> PHONE 92 �. <br /> ( ) ROS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> cam_ <br /> v v.i CHECK If BILLING ADORE$$ <br /> BUSINESS NAME (� — <br /> �-j PHONE# En, <br /> NOME O( AILING ADDRil ZIP <br /> FAX# <br /> Cm (209 <br /> n STA zip <br /> BILLING ACKNOVYLEDGC) X <br /> EMENI: 1, the undersigned property or business owner, operator or authorized.agent of same, <br /> aclvlowledge 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 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,Sti S ATF an FrDlEli taws. <br /> APPLICANT'S SIGNATU <br /> I DATE: Y <br /> PROPERTY/BUSINESS OWNER❑ t� <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTlL�''"' <br /> #rAPPL7CANrls not the Bu,, CPART_Y,proiautlmritation to sign is regRired//� Titre <br /> AI1T$OBIZATION TO RELEASE INF <br /> 10Torlltatio0 ORMA'T'ION: When applicable,1, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br /> provided to me or my representative. same time itis <br /> TYPE OF SERVICE REQUESTED: ti <br /> �ai T <br /> ACCEOTED BY: <br /> ASSIGNED TO; <br /> EMPLOYEE#: DATE: <br /> . <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> Q /�/ �U SERVICE CODE: PIE: <br /> Fee Artivunt• Amount Paid <br /> Payment Date <br /> Payment Type Invoice# Check# ' <br /> Received El <br /> END 48-02-025 <br /> REVISED 11/172003 SR FORM(Golden Rod) <br />