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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s,�-o u oo c) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME f <br /> SITE ADDRESS <br /> I1`t Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1316,. A 5 Mon6oc� Sk <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# -1 J <br /> (a).,)-\ A-4-0 <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE#. EXT. <br /> (ao q�� Sy�� <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY C\ STATE f ZIP S-�O <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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If 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/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at th same time it is <br /> provided to me or my representative. If <br /> q/� <br /> TYPE OF SERVICE REQUESTED: n•61t IvtS e �V <br /> COMMENTS: NOV O <br /> JOAQUIN 2022 <br /> NBgL pEPy <br /> ACCEPTED By � � EMPLOYEE#: DATE:ll �2I <br /> ASSIGNED TO: Gn EMPLOYEE#: DATE: ' -Z f <br /> Date Service Completed (if already c pleted): SERVICE CODE: o (9A P 1 E: <br /> Fee Amount: o Amount Pal �s�. D(� Payment Date 2Z <br /> Payment Type Invoice# Check# Receeved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �r_0 <br />