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! =3 SAN JOAQLCOUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2O047-93 ed <br /> OWNER/OPERATOR <br /> /J ` <br /> o` CHECK If BILLING ADDRESS CI <br /> FACILITY NAME � a <br /> SITE ADDRESS <br /> Street Nu er Direction Street Name Cft Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE M EXT. APP# LAND USE APPIJCATIoN# <br /> PHONE R EXT. B05 DISTRICT t OCATrON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME P # ' <br /> I � 3 2 7 o2�2J <br /> y <br /> HOME or MAILING ADPRES§ FAX# <br /> .24- 1 ( ) <br /> CITY <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 my business as identified on this form <br /> I also certify that I have prepared this application and that the works to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �/} <br /> APPLICANT'S SIGNATURE: f-rri:OZ - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 'OTHER AUTHORIZED AGENT❑ <br /> 1f APPLrC:ANT is not the BrLLBvG PARR proof of authorization to sign is required Titre <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. r A INI ENT <br /> Arm <br /> TYPE OF SERVICE REQUESTED: �j <br />{ COMMENTS: fes/ S ��' of JUN 2 3 2005 <br /> SAN JOAQUIN COUNTY <br /> �0 ENVIRONMENTAL <br /> , HEALTH DEPARTMENT <br /> I \ ' <br /> 7 Q <br /> ACCEPTED BY: EMPLOYEE#: f -i DATE: �3 ► <br /> ASSIGNED TO: ' _ EMPLOYEE#: 1 �j � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S2 PIE: ,2&01 <br /> Fee Amount: 6 D o Amount Paid �C _� Payment Date L 1-;1-3 1ZS— <br /> Payment Type ✓ Invoice# Check# 1 b� ' Received By:� <br /> I <br /> l EHD 48-02-025 SR FORM(Golden Rod) <br /># REVISED 11/17/2003 <br />