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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID # SERVICE REQUEST # <br /> � s -"f) v� � �azv � �` SR 008SS 2�1 <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ <br /> k'I'a) P� <br /> FACILITY NAME tNumber <br /> SITE ADDRESS � tjC1 q �� � Zi Code <br /> StrDirection Street Name Cit <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT �71 LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , � ('� / J_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME J (v\ PHONE # ExT' <br /> Ik <br /> HOME or MAILING ADDRESS FAX # <br /> ( ) <br /> CITY STATE 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 or <br /> activity 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, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : �� .C� Q,Qy -�—ty DATE : 0 11 ,�!'� a� <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER [3 OTHER AUTHORIZED AGENT � � 4vccAy <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 <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It IS provided to me Or <br /> my representative . Vzol <br /> r <br /> TYPE OF SERVICE REQUESTED : ' ` REI. <br /> COMMENTS : ST M a- 'l\0 O r � ( ^ 0� a " �c � JUL 14 <br /> 2022 <br /> SAN JOAQUIN <br /> HEALTH DEAR NT, <br /> ACCEPTED BY: EMPLOYEE # : DATE : ! �� <br /> ASSIGNED TO : ta EMPLOYEE M DATE : <br /> IAP <br /> Date Service Co Dieted (if already completed) : � 3 2 SERVICE CODE : �9& PI EQ <br /> Amount Paid Payment Date <br /> Fee Amount : � � 3 �2 . U� 2� <br /> Payment Type , Invoice # Check # C46- - I Received By: <br /> u uA .e -� D Lop fec of ? a <br /> EHD 48-02-025 n ,�� r D (�� SR FORM (Golden Rod ) <br /> 07117/08 ��`� <br />