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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT•EPARTMENT <br /> *8-334133 <br /> SERVICE REQUEST � f <br /> *OWR <br /> nes r rope FACILITY ID# CE REQUEST# <br /> Qhs' 6�. 4041�q g <br /> BATOR t ` CHECKif BILLING ADDRESS❑ <br /> :C1 <br /> FACILITY NAME / • om" <br /> d1A13/d/74, I' <br /> SITE ADDRESS Street Numbecon <br /> Name ✓V" Z <br /> HOME Or MAILING ADDRESS (if Different from Site ddress) td5 <br /> lanStreet Numher tr et <br /> m4� <br /> CITY ST 07 2 ZtP <br /> I PHONE#1 ExT• APN# ` LAND USE APPLICATION# <br /> PHONE#2 Ext BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR r l CNECK if BILLING ADDRESS <br /> r / PHONE J r, Exr. <br /> BUSINESS NAME t/-fin <br /> i <br /> HOME or MAILING ADDRESSf"ru" vim <br /> FAIC <br /> r <br /> CIN STATE IP <br /> BILLING ACI N476NVLE GEMENT: 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 Ine 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 JoAQU1N <br /> COUNTY Ordinance Codes,Stand71g! <br /> RAL laws. y <br /> DATE:. <br /> APPLICANT'S SIGNATURE: n <br /> PROPERTY/BUSINESS OwNER❑ GER © OTIIER AUTHORIZED ACENT� <br /> ffAPPLICANTis 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: CtS r F ( f <br /> COMMENTS: 292005 <br /> sAN jOaOUI <br /> lil��i-y ONaR�°�Nry <br /> NT <br /> ACCEPTED BY: (�LtL�t <br /> EMPLOYEE 3 Z, !DATE: <br /> TE: <br /> ASSIGNED TO: <br /> EMPLOYEE O 3 ft <br /> Date Service Completed (if already completed): SERVICE CODE; �(� P t E: 3. O� <br /> Fee Amount: Amount Paid Payment Date <br /> 7-9. Cro <br /> Payment Type / invoice# Check# p Z� Received By: <br /> SR�101�M I�oldert Rost) <br /> EHD 48-02-025 <br /> REVISED 11117/2003 <br /> T -d zf,E9T9f,60a OUI SJO40e.114u00 n`I 84113 dST :EO 90 ET oeQ <br />