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091:12/2003 15:15 2094683433 FIFTH FLOOR <br />aAN JUAQUAf AUNTY E+'NWRONMENTAL HEALT EPAKTMENT <br />SERVICE RF.nYFFQT <br />PAGE 02 <br />v VLA 11�AV 11J.R / ilL' Jr%. V A .L' 1<L' %ZUL' 3 JL V.K <br />REQUESTOR <br />Htr,,hwcL Gb.R2uTk CHECK if BILLING ADDRESS <br />BUSINESS NAMEPHONE# EXT• <br />Ft 11Hc L ( 9/4 7Z- l `18S Z,O? <br />HOME or (MAILING AL)DRESS�vQ FAX# <br />3✓[ wp� c g/61372—off/ <br />CITY ►M�l�fQ STATE CA ZJP `/d <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 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'rATE and FEDERAL laws_ <br />APPLICANT'S SIGNATURE: � DATE: q— &3 <br />PROPERTY/ BUSINESS OWNERR"" OPERXTOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13' <br />IfAPPLICANT is not Me RILLINGPAR7Y 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 assessmcnt <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 />4"t&u 4f <br />EE� <br />SEP �. 6 20(13 <br />pUIN GOUtlTY ' <br />APPROVED BY: <br />EMPLOYEE #: <br />J <br />PUQJMEgi_SH <br />SI <br />ASSIGNED TO: <br />EMPLOYEE 0: <br />7 ) <br />DAYE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount:�q 00 <br />Li'l .L • <br />Amount Paid <br />�+� <br />�.27 1 <br />Payment Date <br />Payment Type <br />Invoice. # <br />Check # <br />0 b� <br />Received By: <br />EHD 48-01-025SERVICE REQUEST F <br />REVISED 6502 <br />