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SANJOAQUr 7'01JNTY ENVIRONMENTAL HEALT 1EPARTMENT <br /> ti SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# :::::DSERVICE REQUEST# <br /> dt�q.z�01/ <br /> OWNER OPERATOR <br /> ' i 1110 <br /> CHECK If BILLING ADDRESS <br /> FAciun,NAME <br /> SITE ADDRESS 23233 Al, JacAL %rhe �Z <br /> Street Number Direction Street Name f <br /> C " fnC PtG 2.C`ode: <br /> Hor AILING AD ESS (If Different from Site Address) <br /> O <br /> Street Number Street Name <br /> CITY /a / STATE C4- <br /> Zip <br /> �� ^ <br /> PHONE#1 Exr• APN# LAND USE /y-TION# J <br /> (w` ) 3 00 - Z - zz OS�a y53 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / / / <br /> CHECK If BILLING ADDRESS <br /> / ��JJ l� CCCJJJ 3 . <br /> BUSINESS NAME � J v PHONE# <br /> HOME or MAILING ADDRE (� FAX# <br /> 12SS- 1 w. (zo9) <br /> CITY Z-- e—' C74 STATE /4 <br /> ZIP Z /1 <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 farm <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: `2� � ___� DATE: <br /> ( <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT JX <br /> IfAPPLIC.'4NT is not the BILLING PARTY proof of authorization to sign is required Title <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 HEALTH 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: S ,rL-ir-Ar <br /> CORMEHiS: RECEIVED <br /> JUN 6 2005 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: G L-I L'E / EMPLOYEE#: (�3 z / H DEP&H j <br /> ASSIGNED TO: il-(&-x) r�V r'1 EMPLOYEE#: S" 3 DATE: 6 "(E, &QS <br /> Date Service Completed (if already completed): SERVICE CODE: /S PIE: Z G� <br /> Fee Amount: � ,� , o D I <br /> Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />