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918/1005 •0 2094 433 PAGE 01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI3 Dm ARTMENT <br /> SERVICE REQUEST <br /> Type of Busineas or Property FACILITY ID fl <br /> 000 oq 3 EQuesr# <br /> OWNER/Op RATOR <br /> FACILITY NAME CHECKifBiLL ADDR S <br /> SITS DRESSI p, C lj��: �►•` <br /> Street Number <br /> HOME or MUNI;ADDRESS (If Dif}Orent from Site Addrass) cI I ecce <br /> CITY t umblt h et Neme <br /> STATE Zip <br /> PwONE>C1 Ext. APH0 <br /> ( ). LAND USE APPLICATION <br /> PHONE 2 Ext <br /> ( ) 803 bl4TRICT LOCATION CODE <br /> CONTRACTOR/SERVICE•REQUESTOR <br /> ReQUE TOR � � <br /> CHECK K BUNO ADogE5 <br /> 9 LJ <br /> BUSINEU NAME <br /> PHONE# E7n. <br /> HO r U DRESS ell <br /> M.. <br /> FAX S _ <br /> CITY <br /> STATE ZIP <br /> SII. <br /> LING ACKNOWL. DGE ENT; I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific WnRONMENrAL REALTH DEPARTMENT hourly charges associated with this project <br /> Of 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 wi <br /> COUNTY Ordinance Codes,Standards,,S- an ,laws <br /> th all SAN lOAQurN <br /> APPLICANT'S SIGNATU <br /> l Dn.TE: d1 —/d'—O,.0 <br /> PROPERTY/BUSINESS OWNER OR ANAGER ❑ O1usix,AVTHORUeDAGENT0 <br /> 4fAPP1/C4NT is not the I&L82pAM pro0jojuailtoriZollon to sign/s required , Tlt/r <br /> AUTHO1tIZATxON 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 environnientaUsite assessment <br /> Information to the SAN 10AQUIN COUNTY ENVIRONNONTAL 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 /> Colwtewrs: <br /> AUG 18 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I HEALTH DEPARTMENT <br /> ACCEPTED BY: C�L ��, EMPLOYEE i(f: <br /> AssiGNe0 TO: > DATE: 1 C,j <br /> L EMPLOYEE#: .3 S'�' z.' DATE: r GS <br /> Date Service Completed (if already completed): <br /> SERvrce P/E: <br /> Fee Amount: - Amount Paid <br /> •�'��• �1; .2-71. D C-) Payment Date �•-- <br /> Payment Type I/ Invoice# Check# J <br /> t7 Received By: <br /> EHO 4MZ-02$ <br /> REVISED 11/17/2003 SR FORM(Garden Rod) <br />