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SAN JOAQUIN r`)UNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> - Icy Sro:,AGr # = <br /> ©©3lo1S7 <br /> OWNER/ OPERATOR <br /> _ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS , �,-7-//�. - {S Z�"- <br /> St,eM Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> - Street Number Street Nath <br /> CITY STATE ZIP _ Clq <br /> STICK .) �/C Z o 5— 11 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> z—(Bo -os PA- - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE T <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORNO ' i > S CHECK It BILLING ADDRESS <br /> BUSINESS NAME t PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Srr<I�; _ STATE ZIP <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, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: <br /> { / I��� DATE: i 3 c j <br /> PROPERTY/BUSINESS OWNER CJ OPERAT/�OR//NIANAGERiJ' OTHER AUTHORIZED AGENT❑ <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: CE)V ED <br /> COMMENTS: DEC <br /> 3 20w <br /> I��y L <br /> /2t7'atl -d rz c'J -" C� IUIN C OUNTY <br /> !J/F £�'� �,...+� O.Mt SAN JOis <br /> A ONM <br /> 9d fJn J 3 O '� t HEALTH ENV DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE : /' /' DATE: 3 6 <br /> ASSIGNEDTO: ,O EMPLOYEE [/,L// DATE: O <br /> Date Service Completed (if already completed): SERVICE CODE: fl P/E: <br /> Fee Amount: l�' - Amount Paid -y, �S Payment Date I y 3 0 3 <br /> Payment Type C�AS�\ I Invoice# Check# Received By: t:C_ <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />