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C) 5 `-tbOb2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ✓lp <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> OJY f <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) O<I wC� <br /> sveet N¢mbar fJY Stra¢ Name <br /> CITY STATE ZIP <br /> �C G <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> `6y) <br /> PHONE#2 E". BOS DISTRICT LOCATION CODE <br /> ( 2 U <br /> CONTRA TOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex'' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY G 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 andF <br /> APPLICANT'S SIGNATURE: DATE: c/0 ze, <br /> PROPERTY/BUSINESS OWNERICJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> {'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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/% x+ I/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is a1�171 ��fiiC Same time it is <br /> provided to me or my representative. REC J <br /> TYPE OF SERVICE REQUESTED: SFP 0 7 2022 <br /> COMMENTS: <br /> COUNTY <br /> r Q SAN JOAQUIN <br /> FMARONmENTAL <br /> HEAL'M DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: u3 DATE: <br /> ASSIGNEDTO: EMPLOYEE* DATE: l Z <br /> Date Service Completed (if already completed): SERVICE CODE: PA <br /> I I <br /> Fee Amount: 9' Amount Paid g Payment Date Z Z- <br /> Payment Type 'v 5 Invoice# Che-6k# S C) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> 5 <br />