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l � SAN JOAQU' COUNTY ENVIRONMENTAL HEAL' "DEPARTMENT <br /> 141 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESt# <br /> 11 11 C0 3SC3� <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ITE ADD �) w MA t !(�✓� t � Rbc' <br /> V Street Number Direction Street Name Cit 21 ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EaT. APN# LAND USE AP LI ATION# <br /> (� ) 21 - gal -2 DI 7 0 — y <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> Y - ONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> ti CHECK If BILLING ADDRESS D <br /> USII�ESS HAMS � � i A ' PHONE# <br /> Ext. <br /> ONE Or MAILING ADDRESS 1\/ FAX# <br /> , "ZRF-FIT ( ) <br /> CITY STATE /1 n 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 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 applic nal that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST a cR,AL l/al s. n 2 <br /> APPLICANT'S SIGNATURE: v DATE: <br /> PROPERTY/BUSINESS OWNEREI OPER 011/MANAGER ❑ OTHER AIITIIo R17.ED AGEM� <br /> /f APPL/CANT is not the Bii.LING PART proof of authorization to sign is required 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at [lie sante time it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: J— <br /> COMMENTS: /0 <br /> 2�/8b; 1yv3 RECEIVED <br /> rc��•� �¢. n�� ? t/���./p AUG 2 72003 <br /> Co,,4p"lile 0'' -t- e/� JrC "`�/ "r �[� SAN JOAQUIN COUNTY <br /> Oar" i ed v. S� !© ��IG TI On.cu.u+eir-- 3 - PUBLIC HEALTH SERVICES <br /> APPROVED BY: EMPLOYEE#: t <br /> ASSIGNED TO: EMPLOYEE#: �+/ DATE: a�y -3 716_3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: !60 j <br /> Fee Amount: ( c`6 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM / <br /> REVISED 6-5-02 <br />