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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I D -7 <br /> OWNER/OPERATOR <br /> f I (/f f Z CHECK If BILLING ADDRESS <br /> FADILITT NA Cc <br /> _ I C-flr? <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING AD RESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> C] L 20V <br /> PRONE#f EST. APN# LAND USE APPLICATION# <br /> (2Cf1y�),2�3- 1 <br /> PHONE#Y EST. BOS DISTRICT LOCATION CODE <br /> (ZQ9 ) 2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE& OR <br /> CHECK If BILLING ADDRESS <br /> nI CJc�' <br /> BUSINESS NAME PHONE# EST. <br /> L ' . El L } ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FEDE�laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: 6NU RECEIVED <br /> COMMENTS: <br /> AIL 2 5 2022 <br /> &0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: GJ EMPLOYEE#: f�0 DATE: -717=--5- <br /> ASSIGNEDTO: W Lrez I <br /> EMPLOYEE#: V V Q- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 03 <br /> Fee Amount: r Amount Paid `� Payment Date <br /> � �. <br /> Payment Type L5 P�- I Invoice# Dh#c-k# J 2 l ZS Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ;Pf ko 0 <br />