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SAN JOAQUIN r'OUNTY ENVIRONMENTAL HEALTH I)EPARTMENT <br /> --� SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICL REQUEST# <br /> OWNER/OP—EIRATOR <br /> \ C�)S:`(� c'Ct <br /> FACILITY NAME \ CHECK If BILLING ADDRESS❑ <br /> J 1� <br /> SITE ADDRESS K <br /> �% 7 �j c � �--1 ri L�t'r1 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. ]—A N# LAND USE AWPLICATION <br /> # <br /> oa � a-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME �- c , _ PHONE# z ExT• <br /> Av^►�1 t�5i-�. �ih1 TI'1 � ��`�"C1 CSC �1�1 � �1CIitC�tl' 2C��/ ��1 — I _J� . <br /> HOME or MAILING ADDRESS FAx# <br /> CITY JkeC Kt„r� STATE CA <br /> ZIP 9 I — <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 foml <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: Yy1 l` v% 1� �rTyr t+c2..e�_ DATE: ju\\ je- 17., 2002 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT FIyr,-20 , ( ,�C)` <br /> If APPLICANT 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 dat1�. 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: <br /> COMMENTS: <br /> CGr1'.%-O- XC,�,f �G+G ISG .lE.L7GE-J. �J <br /> :� 'r�jl trjrf dGCrf ?:c#'ci l 'ir.�j�"• �N COUNT <br /> $ <br /> PA11BlICOH�A TH SCoc V13i <br /> Y J!I-����•cih - � '3! r.) MEN HEAL <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comple- d (if already c leted): SERVICE CODE: P I E: <br /> Fee Amount: 7 Amount Paid �7 r1 D at <br /> Payment De <br /> Payment Type Invoice# Check# -3902 Received y: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />