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SAN JOAQU COUNTY ENVIRONMENTAL HEALT"DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COOK Kd#-C r�1 t C4ICQ S C\ 0033993 <br /> OWNER It OPERATOR (( -r- <br /> UI P4C1 ?t PL�M��[n S Se.VRR y/tt CHECK If BILLING ADDRESS <br /> 4 <br /> FACILITY NAME <br /> 1/q U'�'Z- p•c.+vo lY.cA l.... SrC u,2<, marc. - La cQl <br /> SITE ADDRESS 20 I C+o r �� (,o d .' ysiyv <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /Lb p,,-'k W + Ctre(r- Street Number Street Name <br /> CITY STAC� ZIP �i.TZ-O6c <br /> '5-1OLk�1, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (z-9) 4y�-9ylL <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Sc So 4 Aso <br /> 1I- � CHECK If BILLING ADDRESS <br /> -Y0/lASoh PC�i/UIr:..Nn (J�KS1N�l c�l�9N SNt: <br /> BUSINESS NAME PHONE# ExT. <br /> " 5-3 16-It -('e34 <br /> HOME Or MAILING ADDRESSFAx# <br /> Pb 6-Y 7 1L�I ( S30 1 R-7$ -(0`l31f <br /> CITY STATE �. ZIP FS-40`/ <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. <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, S"PATE and FEDEI laws. <br /> APPLICANT'S SIGNATURE: —�� DATE: .�/r-03 <br /> PROPERTY/BUSINESS OWNER OPERAT li/MANAGER QTItER AI'TIIORIZ.F.D ACF.NT❑ <br /> /f 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 data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and 4the same time it is <br /> provided to me or my representative. YM� 1 <br /> TYPE OF SERVICE REQUESTED: US T J c�r i f RvaC <br /> COMMENTS: r,lt A`� <br /> 103133 <br /> t'IP`AN`O N�p jHS RH�E g\ON <br /> EMIIPONMENTAE HEAL <br /> APPROVED BY: EMPLOYEE#: �p'lL Z DATE: <br /> ASSIGNED TO: D&yh� U9- EMPLOYEEMr� 3�� ^ DATE:r,vIlq <br /> Date Service Completed (if already completed : SERVICE CODE: I q X P 1 E:13 C,� <br /> Fee Amount: 1,(Q� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />