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\', <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # EXT. <br />SERVICE REQUEST # <br />FAx # <br />CITY C,p STATE C ZIP <br />ACCEPTED BY: <br />SR00g5B©0 <br />OWNER / OPERATOR <br />CHECK BILLING ADDRESS <br />v V \ <br />�QA �>� <br />O �O <br />If <br />FACILITY NAME <br />DATE: J iJ <br />SITE ADDRESS q <br />) ` {� ►�� <br />C R Vv� <br />C1 S a D'[� <br />Street Number <br />Direction <br />Street Name <br />Payment Date <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Check # I <br />S• C Street Number <br />Street Name <br />CITY L ` � o <br />STATE � ZIP C <br />` J `J <br />EXT• <br />PHONE#11 +� <br />APN # <br />LAND USE APPLICATION # <br />(nC <br />PHONE #2 EXT. <br />BOS DISTRICT L <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />v, CHECK If BILLING ADDRESS <br />BUSINESS NAME\tea` <br />PHONE # EXT. <br />HOME Or MAILING ADDRESS � ' � �1 � (1 � <br />FAx # <br />CITY C,p 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 <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 13 OTHER AUTHORIZED AGENT E3If APPLICANT, its not the BILLING PARTY_proofofauthorization 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. <br />TYPE OF SERVICE REQUESTED: Sa I SU : AL + II GHGl <br />AJ / f r!1 he P.0 <br />COMMENTS:T <br />Reciwp <br />SEP 2 0 2022 <br />H N10 <br />V/R0NINC0UN1Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />I <br />EMPLOYEE #: <br />DATE: J iJ <br />Date Service Completed (if already completed): <br />SERVICE CODE: e 3 <br />P / E: 9 <br />Fee Amount: <br />Col I <br />Amount Paid <br />W2I! <br />Payment Date <br />ftu7�2— <br />Payment Type <br />Invoice # <br />Check # I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />