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or <br />• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type qusiness Property_ FACILITY ID # <br />SERVICE REQUEST # <br />AYMEN <br />CHECK If BILLING ADDRESS t <br />OWNER OPERATO R <br />E] <br />((j' <br />,! <br />v �/c^ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />VC6 <br />Ito$ <br />SRE DDRESS <br />Street Number <br />Direction <br />Street Name <br />HOME or MAILING ADDRESS <br />' <br />kini <br />e <br />HOME or MAjL#NG ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 -r Ext. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />J• <br />AYMEN <br />CHECK If BILLING ADDRESS t <br />r� <br />2 4 2005 <br />BUSINESS N41E ) <br />l <br />Ito$ <br />JAN <br />_ Exr. <br />HOME or MAILING ADDRESS <br />' <br />auw <br />SA ENTN pEPAEgTAL <br />RTM � <br />FAx# <br />��e L <br />�) <br />e) <br />CITY 1 I/ /) rn j <br />� STATE <br />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 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 Standar TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: / G <br />DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If 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: �� T <br />L <br />AYMEN <br />COMMENTS: <br />r� <br />2 4 2005 <br />JAN <br />oouNTM <br />auw <br />SA ENTN pEPAEgTAL <br />RTM � <br />ACCEPTED BY: LSV � <br />EMPLOYEE #: C � D <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: �C <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/1 <br />P i E: 2 Q <br />Fee Amount: ' ' <br />Amount Paid <br />IV <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 4730 <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) 1 <br />REVISED 11/17/2003 <br />