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02/25/2005 16:37 2094683433 FIFTH FLWR PAGE 02 <br /> OPLN dIvAIJUJUN t--JUIN L Y ZIN VJKkXWMLiN'I•AL "EALTH DF, RTMEN'f <br /> SERVICE REQUEST • <br /> -ype of Business or Prop" FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> 13 <br /> FACIIrryNAME CIA 1.,1 f:70 VN I 1A :Si—p to <br /> SrM ADDRESS 2 2,Z_c4 M -- =-L'( <br /> sow umber Direetian Str*&I N2M9 a Zi e <br /> HOME or ftI1AILING ADDRESS (If Different from Site Address) <br /> Street Number Strrrt Nam <br /> CITY STATE ZIP <br /> PHONE 91 EkT• APN# LAND Use AppucAmoiq# <br /> 1 1 <br /> PHONEN2 EXT. 1308 DISTRICT LOCA71oN CODE <br /> . 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESmR �/ <br /> CHECK if BILLING ADflRESS•p1 <br /> BUSINESS NAMEPHONE# E <br /> A (20 q )-5-3-2--7 32 v <br /> HOME or MAILING ADDRESS FAX# <br /> oT2 3- � <br /> CITY S 0 /� n STATE ZIP q --T O <br /> BILLING ACKNOWLEDGEMENT- I, the undersigned property or business owner, operator or authorized.agent of same, <br /> acknowledge that ail site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billcd 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: 2(fl C'S— <br /> PROPERTY/ <br /> S— <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTIR CO/ylPL f 09AI cr, T'E SIFT? <br /> IfAPPLIGINT is not rheBILLlNG PARTY proofof authorization to sign is required Thle <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 DBPARTmENT 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: E'PtA c A/L f tiJ G- L E4 - • <br /> COWARS: <br /> S T 1`9--F 'Te o F-('T- <br /> d? <br /> M /VaNumy <br /> ACCEPTED BY: t'�i ��r� EMPLOYEE#: 3 2 1 DATE: Z <br /> ASSIGNED TO: S G/ EMPLOYate#: >> i DATE: -�2 <br /> Date Service Completed (if already completed): Senv CODE.. / P t E: <br /> Fee Amount: c, �, Amount Paid _ fl(� Payment Date <br /> Payment Type Invoice# Check#f Received y: M <br /> V\ ' <br /> EHD 48.02=425 7-7-1 <br /> REVISED 1IJ17/2003 <br /> FE6 <br /> ENVIRONMENT HEALTH <br /> pF ,IINT%SERVICES <br />