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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o S+ CLO co DO q <br /> OWNER/OPERATOR <br /> \ n V, ` c CHECK If BILLING ADDRESS <br /> FACILITY NAME 1' ` � �UI` r J <br /> l.0 CU E-1 mG ll.c, <br /> SITE ADDRESS 13 p C]. Ce%,4 4 . <br /> Street Number I Direction l u SVeet Name city Zip Code <br /> HOME Or MAILING ADDRESSIf Different from Site Address) <br /> Veet Number Street Name <br /> CITU 60STATE CA ZIP 7e7RV� <br /> PHONE#1 Exr_ APN# LAND USE APPLICATION# <br /> (ei0q) Co P51 <br /> HONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE If Em <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNO GEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTN 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❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BiLUNc PARTY,proof of authorizadon to sign is required Tine <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 HEALTFi 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: � Vety"%ri(c t II/1S P( L` MENT <br /> COMMENTS: D <br /> NOV 0 7 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE III: DATE: I �� <br /> AsSIGNEDTO: EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already Completed): SERVICE CODE: 00 1 P/E: <br /> Fee Amount: Amount Part S� Oa Payment Date 7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />