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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR ` <br /> U` <br /> d /� 1� C C) CHECK If BILLING ADDRESS <br /> FACllltt NAME (1 1 1e� ,p` ,� � I — <br /> SITE ADDRESS 2t4 "l PSI �� �V J SSV�cT-X \ RS X17 10 <br /> Street Number 01 rection Street Name CI 21 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 43 C-kro.t� -e <br /> Stre¢t Number Street Name <br /> CITY STAT ZIP 9 S �0 <br /> PHONE#1 E , APN# LAND USE APPLICATION# <br /> (2e) 9 22 - la <br /> PHONE#2 E%T• BOS DISTRICT LOCATION CODE <br /> (20A) q S-:� 19 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 \ v`l ' _ w PHONE# EST. <br /> HOME or MAILING ADDRESS FAx# <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 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: KEICEIVED <br /> COMMENTS: FEB 0 3 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L EMPLOYEE#: DATE: 2 - 3 - 22 <br /> c <br /> ASSIGNED TO: L '� Y\��0A/- es EMPLOYEE#: DATE: 2 - 3- 22 <br /> Date Service Completed (if already completed): 2 - 3 - 2 2 SERVICE CODE: 1bo3 1 PIE: �� 1 <br /> Fee Amount: r5 2 — Amount Paid /S2 _ Payment Date a /3 ' a <br /> Payment Type V L S Invoice# Sheak# 3 g 3lo a a C) Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 71/17/2003 <br />