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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # , SERVICE REQUEST # <br /> s-f a LA- ;�� o Lf 9�� <br /> OWNER / OPERATOR <br /> f6A. <br /> 4 LAO,5 S CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ` L �r( S R� -� O t. CA <br /> Street Number Direction 1 Street Ndme c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I En. APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PFAx # <br /> `t A t�3 .. CQ63� ExT. <br /> BUSINESS NAME A ( r� t 1q „ _ � ` u `t�S <br /> HOME or MAILING ADDRESS IJP <br /> UIL <br /> CITY zajQ. � 6 ��-� STATE C 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 : ' � �11�iti ` �"-r � -� DATE : /���( (1 ', I ' ,{ n <br /> PROPERTY / BUSINESS OWNER 13OPERATOR / MANAGER 13 .L7 <br /> OTHER AUTHORIZED AGENT to LWZ (.lW <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 /> to 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 . <br /> TYPE OF SERVICE REQUESTED : YMENT <br /> COMMENTS : <br /> S�� f cedar r� �r OCT 0 3 2022 <br /> ziAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I4EALTH DEPARTMENT <br /> ACCEPTED BY : S EMPLOYEE # : DATE : V �Z <br /> tZU <br /> ASSIGNED TO : G' �� EMPLOYEE #: DATE : / - <br /> Date Service Completed ( if already completed) :' SERVICE CODE: /gf-", ,�7 90 P / E : ? (� 9 <br /> Fee Amount : y sAmount Paid ��� Payment Date <br /> Payment Type Invoice # Check # q3 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />