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©5/27/2005 15:26 2094633 F?FTH FLOOR • PAGE 02 <br /> SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUN 10# SERVICE REQUEST q <br /> Fu d" s t �/� s i©rte _;c S �f'167-1 <br /> OWNEFOOPERATOR 1 <br /> U e*0 CHECK It EILUNd Arpuss Er <br /> FAmmylil NE Uotr CA� tS_ pcnAt ---- <br /> SITE ADGD./REEss <br /> r /� � Strxi Num er araction G`^c' 1`' U �gtred— �J 1 �SGPI OK �5,3.� <br /> HONE or MAILING AnD?tM {If Dh%rent from Site Address, <br /> strNt Numha I SfreM Nem <br /> CITY STATE zip — <br /> PNOW#1 sn. APNt <br /> t�tNo Use AAPLICAl10N# <br /> PHONE 92 e.r. BOS MSTR;CT IACr T10N COLE <br /> 1 <br /> CONTRAC'T'OR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If SUNG ADQW-$ <br /> BUSINESS AME l PNOaE✓S , <br /> e s -,Lsa- <br /> HOMeOrMAILI ADURESS FAX# <br /> CITY n1� o-'ln l STATE G_2h ZIP <br /> BILLING AC#KNOWLFDGEMBNT: 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 we 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 JOAQL <br /> COUNTY Ordinance Codes,Standtrdr,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � � DATE: %D <br /> PROPERTY I BUSINESS OwN6R❑ / OPERATOR INTANAGIM OTVEe AUTtoatLEn AGENT <br /> if APPLlrAM is rddl rhe R!tjgic PAg proof of aathd tzmion to sign is requited Tit!e <br /> AUTHORIZATION TO BALE 9—E IVBORNIATION:When applicable,I,the owner or operator of the property located at fie <br /> above site address, hereby authorize the release of airy and all results, geotechnical da 7gC"906 r�"twa6he assessment <br /> inf•:mlatiOn t0 the SAN JOAQUIN COUNTY EWIRON.MENT'AL HEALTH DEPARTmm-T as soon;Ftt3JF!Jk*6d at the same rm.e it is <br /> provided to me or my representalive, rrr��� 4 <br /> TYPE OF SERNCE RWUESTED: <br /> Cosimnis: <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENIAL <br /> rjEALTH DEPARTMENT <br /> Accer=re0 Br. L t u e,.k'?{ EmFLoree#: .5 Z_I MTC: // c <br /> ASSIGNED TO: 0,37-A--qA C� E'uPLOYEE#: ,i?-?,F qT— MSe: /r ; C,S• <br /> Date Service Completed pr already completed): SEAVCEC": 7 PIE: <br /> Fee Amount: -�-1, - , Amount Paid '�5 D--J Ct. C) p Payment Date Ll 3 <br /> - Payment t Type Invoice# Ch"ch# 13 Received By <br /> -HO 43.02-025 3R FORM(Gorden Rod <br /> nEVISEO 11/17!2003 ) <br />