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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMLNT f <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> cn <br /> FACILITY NAME <br /> SITE <br /> // <br /> E ADDRESS All_ &140 /-DID 1, 9sZyU <br /> le W 8 t0 Street Number Dir ton Jl n Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) '0!l - /20- 0 � �4 - CMS <br /> PHONE#2 ExT 4BOS DISTRICT LOCAn DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS El <br /> SiM RVA�J <br /> BUSINESS NAMEi PHONE# ' <br /> nM�J4 c-h � �IhZ Z�I yn c- ZO9 3&&- /D/Yf8 � <br /> HOME or MAILING ADDRESS' ^^ FAX# <br /> 23 W. rL_A4 5'I, (209) 3lp8 - !a(olD <br /> CITY J O D/ STATE !� ZIP C� 5-Z yO <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, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 7/��_ DATE: 3–/0 –0 <br /> PROPERTY/BUsiNESs OWNER /OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tide <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 at the same time it is <br /> provided to me or my representative. 'P'A y <br /> CE <br /> TYPE OF SERVICE REQUESTED: p IL- S ce I—)�},�Ij t t_ <br /> COMMENTS: SIV <br /> NEACTl AD'cPARVTT Nry <br /> t. <br /> 3fl�rvu� y a���. S.��Q ' I�H✓mc,.�('�1 ..cam+ EPgRTMEMI' <br /> ACCEPTED BY: L I v E I Fp EMPLOYEE#: ,�j Z/ DATE: #E �ASSIGNEDTO: EMPLOYEE#: �3 6DATE:Date Service Completed (if already completed): SERVICE CODE: s j 22Zj <br /> Fee Amount:<9 Amount Paid a ( � Payment Date 3 \ \ O I <br /> Payment Type f Invoice# Check# Lk A `S Received By: WTZ–.— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />