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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> / C1 �ar A r,��l 515 ��D� 7 73 <br /> OWNER/OPERATOR <br /> 2 / CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /� h G'' 0 I/D Ti'r—eZ6 <br /> =0 7 Street Number Direction c J / Street Name � City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �n�� <br /> Z d 0 �G l�icJ/ 7n G ' ST�� / <br /> Street Number Street Name <br /> CITY S*T Zj_v/--l STATE, ZIP?SZn r <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#Zll� EXT, EM L Gi�/n BOS DISTRICT LOCATION CODE <br /> (�1 <br /> CONTRACTOR / SERVIC REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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,, STand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �.� DATE: O <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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is provided to me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: L4 I <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: LJ ctQ u' EMPLOYEE#: DATE: l Com' <br /> Date Service Completed (if already Completed): SERVICE CODE: / _ PIE: 1 <br /> Fee Amount: (%w Amount Paid Payment Date <br /> Payment TypeC Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />