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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> xt-.kIc1ILT, ktw� 207-2Tja-�6ciT�9 SReo _33q J <br /> OWNER/OPERATOR T p T <br /> TCS <br /> y LYT lr j, J R CHECK If BILLINGADDRESS <br /> FACIU(Y NAME r <br /> SITE ADDRESS I.Ci C �'.�arw'.= Qri o,C )AA <br /> Street Number Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7J <br /> Street Number Street Name <br /> CITY t/( cr.�. STATE �� ZIP <br /> PHONE#1 EX. APN# LAND US�E,�A,-P7PLICATION# <br /> ( �9) �A-IL— Inian 20% O/O—• 0:, ��: PA - C... I' V <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR •/0A+-�-7£q G C,yk?�_ CHECKIf BILLINGADDRESSID <br /> BUSINESS NAME PHONE# Ex. <br /> Col ')'ie, r. cCXJ x4,13— 41" <br /> HOME or MAILING ADDRESS FAx# <br /> 4 ig MRT-> PLAzf I ) SVG <br /> CITY i nl;i STATE i,f 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 project or <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' ' /' s , DATE: E. <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ID f:" <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required / A 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: EOE" ;,.�±;T A t:,t='T/ .`-_,Z" :a" FUNEr '�.`/�� <br /> COMMENTS: d�,t�j63 �r' RECEIVED <br /> / JZ4��//'4°`" MAY 2 1 2003 <br /> �� (p SAN COUNTY <br /> PUBLICC HEALTH HEALTH SERVICES <br /> ENVIRONMENTAL.HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: 2,2 [11, DATE: 5-2.1 -03 <br /> ASSIGNED TO: - EMPLOYEE#: DATE: Z I Q <br /> Date Service Completed (if already completed): SERVICECODE: �'-j-'-Z PIE: -Z(G() / <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br />