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SAN JOAQUI "OUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 1 FACILITY ID# SERVICE REQUEST# <br /> PA5TWF- 191F-51P4Wr/A 35 <br /> OWNER/OPERATOR <br /> Al 1Z n7R 5. T1oBEQT �A 4 AM R- AIE- ,Q�- CHECK If BILLING ADDRESS <br /> FAcurtKue <br /> $READDRESS .303V BAST ONE TREE tD- OAKDAGE 9536/ <br /> Street Number Direction Street Name cibr Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT' APN# LAND USE AP PLI ATION# <br /> ao -a o - a -1J56y�lyts <br /> PHONE#2 Er. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dom Gk,� `w <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME /� T /T • /� /1 „ ,t/ !'uL r/AJC PHONE# / ` e— 415i? ' <br /> HOME or MAILING ADDRESS ,V FAX# (�(p <br /> CITY t2 L STATECA ZIP /-S-3. <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 3 <br /> I also certify that I have prepared this ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and F L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ THER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of aut orization 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5U AC N B ivxFA T tz /zEV F VJ <br /> COMMENTS: &--P6a-r Zed %�q/y� 0 d m-�, �C VED <br /> �lt3rlc� �y� Fl <br /> .yI 'r� Esc o AUG 16 2005 <br /> QUI <br /> /V <br /> �TVIR01VAk OU <br /> N D NT <br /> ACCEPTED EMPLOYEE#: II g- Q <br /> ASSIGNED EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 11 P1 E: - 3 <br /> Fee Amount: © Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />