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SAN JOAQUI7OUNTY ENVIRONMENTAL HEALT"-DEPARTMENT <br /> SERVICE REQUEST -" <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS IR <br /> Sr (/n �rtvoo —13�¢ <br /> FACILITY NAME <br /> SITE ADDRESS 9.cl r/q hCC N) t' r FJ�4"os CI!" <br /> Street Number Direction Street Name 1 Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) rJV ✓V, W6 p pt S !)V- . <br /> /' /tea 3 ,5` Street Number /^ /� Street Name p <br /> CITY Lb 5 C�0-+0 5 CA STATE 3 / ;Z q5— <br /> PHONE#1 Exr. APN# LAND USE APPLIC'ATITIOIN# <br /> ( ) 067- 31v <br /> PHONE#2 Exr. BOS DISTRICT LOCATION(;ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,/2cr 1G S� fj e,, CHECK if&LLINGADDRESS❑ <br /> „/ ! PHONE# Exr. <br /> BUSINESS NAME -�3 <br /> HOME or MAILING ADDRESS Z <br /> ` ,/ <br /> CITY I _ 1 STATE ^ ZIP ,qS'2-�r V <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, o!peerator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvTRONMENTAL 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 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: -- � /�— DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ AVER AUTHORIZED AGENT❑ <br /> IfAPPLlcANT is not the BILLING PARTY.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 environmentaUsite assessment <br /> information to the SAN JOAQUIN Comes 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: /Qie(//�pstJ �O/ (/! h/4 T <br /> COMMENTS: .! ./�.� ..)1 jA1 ry i 2006 <br /> [IL 6 �Z� ��iQ ��'•-� ��,�<® �/ (,'Jlrl courlrt <br /> ;FILTH D ARTMENf <br /> ACCEPTED BY: �.LI L. N �� EMPLOYEE#:l Lg3 DATE: Z.I (CTk <br /> ASSIGNED TO: A <br /> EMPLOYEE#: �3��� DATE: (t, (L-( fok <br /> Date Service Completed (if already completed): SERVICE CODE: S.Z2 PIE: <br /> Fee Amount: (g6o't7 <br /> Amount Paid Payment Date <br /> Payment Type invoice# Check# Received By: <br />