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18/2005 17:11 20946834" FIFTH FLOOR PAGE 02 <br />SAN JOAQUIN CU LINTY ENVIRONMENTAL HEALTH bru.PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OwN0� �oa5� �//�,//� % CHPCKIfEtILLINGADDRESS� <br />Facll'Lr✓NAmE y,�4� , V� _ <br />SrrE ADDRESS ✓�� J� 1 � ��� �/� `✓L1-'1 I�-1 LJI�J ��p C de <br />`--/ y'l�_ Ci Zi Code <br />treet Number Dirsction Street Neme <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY /JG�- // ,,, ,,, J STATE ZIP 9o�a3 <br />PHDNE #1 ( �( / ExT, APN 0 LAND USE APPLICATION # <br />(7l (2-70 5 DLXD <br />�PHONE f;2 Ex-r.UOS DISTRICT LOCATION CODE <br />CONTRACT <br />REQUESTOR 4�4 <br />BUSINESS NAME <br />HOME Or MAILING J4DORESS�� <br />CITY <br />SERVICE REQUESTO <br />CH19CIC if <br />k�) 0) -Sl <br />STATE /( OI ZIP <br />BILLING ACKNO LEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that a site and/or project specific ENVIRONMENTAL HEALT73 DEPARTMENT hourly cllargcs 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 IOAQUIN <br />COUNTY Ordinance Codes, Standards, ST d FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER C3. OTHER AUTHORIZED AGENT U. <br />IfAPPLiC.AN7'is not thelLL1NGPARTY ,proofofauthorizarion to sign is required irte <br />AUTHORIZATION TO RELEASE INFORMATION: when applicable, I, the owner or. operator of the proper located at the <br />above site address, hcrcby authorize the release of any and all results, geotechnical data and/or environmc '' seesss9mlent <br />information to the SAN 70AQUIN, COLNTY ENVIRONMENTAL HEALTH DEPARTMENT a�sQ�oo a5 it is available and at �V <br />provided to nye or my representative. i (M 'l 114A, <br />F <br />TYPE OF SERVICE REQUESTED: V 5T F C_ 1 F O F J_ ( �t <br />COMMENTS: Vx j or <br />ACCEPTED BY: i/� 1414 n ; EMPLOYEE #- J01 I/VI <br />SATE: ) L <br />ASSIGNED TO: ? EMPLOYEE r :#CODE: <br />DATE. <br />Date Service Completed (if already complE�ted): SEP E: d <br />Fee Amount:,Amount Paid. l �vt Date <br />Payment Type Invoice # Check # 7� Received By: <br />SR FORM (Golden Rod) <br />