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08/25/2004 12:19 55948535 BANKS & CO. • PAGE 05 <br />SAN JOAQUIN COUNTY)I NVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I <br />3 <br />FAClIyt,ITY iD # <br />SERVICE REEQ� UEST # <br />r i, C <br />.S� <br />]j <br />V � � ' d6. <br />OWNER l OPERATOR <br />EMPLOYEE ^a . <br />�y <br />DArE9. . v / <br />ASSIGNED TO K i ! " <br />HOME or MAILING ADDRESS <br />WE ":. <br />Date Se'rirrae Co;iittpNeted.; (ifalrea:dy i:omptstetl): <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />P' 14� <br />1 eeAmount -� <br />( ) <br />r• <br />Paynaeef Date <br />STATE +✓ zip 713'70 / <br />Payment Type "' <br />SITE ADDRESSJG <br />0 <br />Check # <br />Sj L <br />Street NumberLy-09-.. <br />Street Name <br />C <br />z, C�� <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />3 <br />oe4,hd K <br />Street Number <br />stmat <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />( Zoo) y/ <br />PHONE #2 Err.. <br />c ) <br />Bos 0szRlc T' ,,. <br />L4�ATICN CODE . <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />&W <br />I <br />3 <br />CHECK if B!4L1NCx ADDRES5� <br />BUSINESS NAME <br />co <br />je.,1fUA7r4 do <br />PRONE # Exr. <br />Q 1 <br />EMPLOYEE ^a . <br />�y <br />DArE9. . v / <br />ASSIGNED TO K i ! " <br />HOME or MAILING ADDRESS <br />WE ":. <br />Date Se'rirrae Co;iittpNeted.; (ifalrea:dy i:omptstetl): <br />FAX # <br />Z. <br />P' 14� <br />1 eeAmount -� <br />( ) <br />CITY Freino <br />Paynaeef Date <br />STATE +✓ zip 713'70 / <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 <br />or 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: .. R DATE: <br />PROPERTY ! E S1NESS Ow: ERM OPERATOR/ NMNAGER © OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the ,BILLING .PARTY. ,proof of authorization to sign is rewired Trrf e RE <br />AUTHORIZATIION TO RXLEASE INFORMATION: When applicable, X, the owner or operator of the property locate Q4 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsi ea ntt <br />information to the SAN JOAQUIN COUNTY ENvIRoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the a time itNi <br />provided to me or my representative. AN 3QAQv�M 1 <br />TYPE OF SERVICE REQUESTED: <br />V S <br />QJ j <br />S7xlt)y,� <br />COMMENTS:/Rep%aet 1.ee-A <br />je.,1fUA7r4 do <br />Vielse/TIh) X170/ <br />APPROV `��` <br />ED HY : U re ��,M�..� <br />EMPLOYEE ^a . <br />�y <br />DArE9. . v / <br />ASSIGNED TO K i ! " <br />EMPLOYEE <br />WE ":. <br />Date Se'rirrae Co;iittpNeted.; (ifalrea:dy i:omptstetl): <br />SERv�c5 CODE l $i <br />P' 14� <br />1 eeAmount -� <br />Amount Paid" <br />Paynaeef Date <br />Payment Type "' <br />Igvolcp'# <br />Check # <br />Recewt d y <br />EHO 48.01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />