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+ SAN JOAQUIN *NTY ENVIRONMENTAL HEALTH DEJfTMENT <br /> ` SERVICE REQUEST <br /> Type of Business or Property FACIUTV RID# SERVICE REQUEST# <br /> I�1 n ; -mark- E o s 64p, an I Do o a I a- va -S <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> I S e 0 <br /> Faca 0.E i 'L I(Yl i n i -I'YI 0..r4 . `�ei�J'c — ` <br /> S ZOOSITE ADDRESS -PaC N,,. <br /> 4 5 11 Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADD R ifferent from Site Address) <br /> Street Number Street Name <br /> CITY ST ZIP <br /> PHONE 91 El APN 0 LAND USE APPLICATION# <br /> (20 ) y-13-111-7 110- 230- l I <br /> PHONE 92 BOS DISTRICT LOCAFION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> ,17; M C o r n e 11 CHECK if BILLING ADDRESS <br /> BUSINEss NAMEPHONES Ex r. <br /> c( ( M �6�- got <br /> HOME or MAILING ADDRESS FAX* <br /> U,,( tce-rne- Ave, . (zek) 44-3Stos <br /> CITY ► .STATE C-A ZIP _{S 2o <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator OT authorized agent of same, <br /> acknowledge that all site and/or project specific ISNVIRONMFNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 , DERAL laws. 2 <br /> A."T ICANT'S SIGNATURE: DATE: 0 3 <br /> PROPERTY/BUSINF'.SS OWNER ANAGFR❑ OT1tFR AUTHORIZED AGENT❑ <br /> If APPLICANT is not the&Z LING PARTY,proof of aathorizalion to sign if required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,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: <br /> COMENTS: RECEIVED <br /> MAR 2 7 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> E RoNmFN <br /> AppaovEn sy: EMPLOYFE I: DATE: <br /> AAssmMED TO: G <br /> EMPLOYEE } SATE: ✓ <br /> Date Service Cormpleleed (if already cnrnln tpol: SERVICE CODE 1 PIE: d <br /> FIE`P_'.i�rn(90.ATAt: Amount Paid C>2 � / n F'.aMent Date 3 c2 7 O 3 <br /> Payment Type Invoice�k Check# OC �v RleceiyQ Bv. <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />