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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�r�� <br />BUSINESS NAME <br />FACILITY ID <br />ID # <br />HOME or MAILING ADDRESS <br />SERVItC11E RE/Q'UEST # <br />Ol��� <br />OWNER QPERATOR ./� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: 2 / P 22 - <br />U <br />ASSIGNED TO: ,.f! <br />SITE ADDRESS <br />I <br />( <br />Date Service Compl ted (if already completed): <br />clr <br />treat Number <br />Direction <br />I Sheet Name <br />Payment Date J 2 -- <br />'� -CI <br />Cor�.do <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Rece ved By: <br />Street Number <br />Street Name <br />CIN ` V C 1\� � <br />� <br />(lg`.-TA� S- Z;5 -0S <br />PHONE #1�y Ems' <br />00`1) �Ut 8 `6 2 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Ex . <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />R;EQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En. <br />HOME or MAILING ADDRESS <br />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. 1 �, <br />APPLICANT'S SIGNATURE: \ (� \ C1 ��I cj V DATE(x <br />62-(S-22 <br />PROPERTY / BUSINESS OWNE'ACLJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLtCANT is not the BILL/NG PAR proof of authorization to sign is required rime <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. PAYouL-. <br />TYPE OF SERVICE REQUESTED: J <br />- <br />Rec <br />COMMENTS: U <br />Ito <br />FEB 15 2022 <br />�V 01V COUryJT, <br />HEALTH DEPART NT <br />ACCEPTED BY: <br />EMPLOYEE#: /'3 <br />DATE: 2 / P 22 - <br />U <br />ASSIGNED TO: ,.f! <br />EMPLOYEE #: <br />&, Z r 3 <br />DATE: .Z t 2 -2 - <br />Date Service Compl ted (if already completed): <br />SERVICE CODE: DG( <br />PIE: (60-3 <br />Fee Amount: <br />Amount Pai /5-Z r b 7') <br />Payment Date J 2 -- <br />Payment Type X45 <br />Invoice # <br />Check # /,3j- <br />03 <br />Rece ved By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />