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SAN JOAQUIN COUN1'4-cT.-rIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> E t & zo LAR S(�C)0341 oa <br /> OWNER I OPERATOR <br /> / ! C / ` CHECK It BILLING ADDRES <br /> / S <br /> FACILITY NAME /ter <br /> SITE ADDRESS <br /> 1 l Pr/='/1 <br /> O'er O Street Number D r♦�on Ff ��y�- Str�Nama � "P OP � Cil � Zi Coae , <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P U • IJTStreet Number Street Name <br /> CITY. STATE IP <br /> lX A-1,Q T A 23 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> I ) 1177 - 1(20 - -3/ 0 - 1 G <br /> PHONE 02 EXT- DOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> RE UESTOR <br /> ` d CHECK if BILLING ADDRESS <br /> X BUSINESS NAME PHONE# EnT. <br /> n 4F-1Z, Co 6 X99 - l 6 <br /> HO E or MAIL ADDRESS FAx# <br /> CITY j C STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIi DEPARTME=NT hourly charges associated with this projector <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 have prepared this application and [hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'T'Y Ordinance Codes,standards PATE and FEDERAL laws. <br /> APPLICANT'S SICNATUIt DATE: 5" O <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTI IER AUTHORIZED ACF.NT� <br /> IfAPPLICANT is not the BILLING PARTY proof of mdhorizdtion to sign is required ride <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HGAL'rH DEPARTMENT as soon as it is available and at the same time it is <br /> - provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (t(qf , W In 5:Ub PAYMENT <br /> COMMENTS: <br /> � JUN 5 2003 <br /> SAN JOAOUIN COUNTY <br /> PUB(� EALTH RVICES ENI ONMENTA EAL H D ISIDN <br /> APPROVED BY: DA EMPLOYEE#: �'Z `L DATE: S�O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed 4if already ompteted): SERVICE CODE: 5ZS PIE: 2(aQ2 <br /> Fee Amount: Amount Paid Payment Date <br /> i <br /> Payment Type Invoice# Check# !. — Recely d By: <br /> EHD 48-01-025 SERVICE REOUEST FORM <br /> RFVISED 0-5-02 <br /> __.. <br />