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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/i <br />� <br />r FACILITY ID <br />BUSINESS NAME <br />(.'I <br />SERVICE REQUEST# <br />CJ{�JV�Ij'k3j <br />PHONE# <br />20 <br />En. <br />S' 33 <br />Db; -4 ✓� <br />LAne <br />3 <br />OWNER/0 ERATOR <br />CITY ' }-byoo <br />CHECK If BILLING ADDRESS <br />LP Icon) <br />?j <br />ASSIGNED TO: <br />FACILITY NAME AC'; n <br />I I <br />12� <br />SITE ADDRESS 3000 <br />SERVICE CODE: <br />1 E: <br />a. <br />Fee Amount: <br />Street Number <br />Direction <br />Street Name <br />2<.1L A <br />City <br />Zip Code <br />HOME Or MAILIIN`IG-ADDRESS (If Different from Site Address) <br />Received By: auzo— <br />SUVCAP <br />Ihyl Ito G Street Number <br />Street Name <br />CITY <br />STATE ZIP �S2 <br />PHONE#1 <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQV ESTOR <br />REQUESTOR S /JYA y)W1 <br />/i <br />� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />(.'I <br />U t <br />PHONE# <br />20 <br />En. <br />S' 33 <br />HOME or MAILING ADDRESS <br />WK G O(Arrrney <br />LAne <br />FAX# <br />CITY ' }-byoo <br />STATE <br />LP Icon) <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 fonn. <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�A1TE and FEDERAL laws. 1 I n ^ I <br />APPLICANT'S SIGNATURE: / lT�' a, DATE: 0� 2 U I2o21 <br />� r <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 environme t assessment <br />Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and tIt l it Is <br />provided to me or my representative. t +� CFn A <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS; <br />cyanx or Hersh <br />EHVJOgQVINC <br />H MpieL44 <br />- FNT <br />ACCEPTED Y; <br />EMPLOYEE <br />DATE: <br />?j <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: 114 <br />12� <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />1 E: <br />a. <br />Fee Amount: <br />Amount Paid <br />I "J a <br />Payment Date <br />2<.1L A <br />Payment Type <br />Invoice # <br />Check # <br />Received By: auzo— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 n 10 054 2-17 <br />