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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACCI <br />ILITY ID # <br />�!py�� <br />AAIZUEIV <br />SERVICE REQUEST <br />j j # <br />OWNER/ OPERATO <br />BUSINESS NAME <br />CHECK It BILLING ADDRESS <br />FACILITY NAME <br />PHONE # EX <br />DATE: 2-3 <br />SITE ADDRESS <br />Street Number <br />/}� <br />Direction <br />/✓. ���_ <br />,/ Street Name <br />tILINGAESS <br />7 <br />CI <br />ys,�yo <br />21 Cede <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />CITY <br />� <br />Street Name <br />CITY <br />Fee Amount: <br />STATE ZIP <br />PHONE#1 <br />( ) <br />Ex. <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />Ev. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I , <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />AAIZUEIV <br />j <br />BUSINESS NAME <br />ACCEPTED BY: <br />PHONE # EX <br />DATE: 2-3 <br />ASSIGNEDTO: <br />OG O <br />tILINGAESS <br />7 <br />_J <br />�!�✓YAn" <br />) <br />fAX#yjO <br />CITY <br />� <br />STATE ZIP �l D <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, Standards, STATE and FE s. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / NItANAGERR OTHER AUTHORIZED AGENT ❑ <br />If APPL/CANT 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 same same time it is <br />provided to me or my representative. ft� MCAO� <br />TYPE OF SERVICE REQUESTED: <br />AAIZUEIV <br />COMMENTS: <br />� I ^ <br />utC <br />JQgQutty 20?1 <br />aiv <br />H D6 M NT <br />ACCEPTED BY: <br />EMPLOYEE #:qK <br />DATE: 2-3 <br />ASSIGNEDTO: <br />EMPLOYEE#: 296 1 <br />DATE: '2 Z <br />Date Service Completed (if already completed): <br />SERVICE CODE:01 <br />P 1 E: <br />Fee Amount: <br />00 1 <br />Amount Pai <br />ISS Ob <br />1 Payment Date <br />I <br />Payment Type <br />Invoice # <br />Check # 3 l l 9- -.2-- <br />I Received By: <br />EHD 48.02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />5 <br />