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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G 25 SR00V & 103 <br /> OWNER OPEOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS t Dire.— CO- <br /> / D 56eame ' 95;03 <br /> ZI Code <br /> HOME Or MAILING ADDRESS (If RIfferent In Site Address) /�1/�"- C -F <br /> 10 Street Number �t e1 el Name <br /> CITY /_© STATEP <br /> PHONE#i L E-• APN# LAN USE APPLICATION# <br /> (9o<V 8 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Ezr. <br /> HOME Or MAILING ADDRESS FAX# <br /> CRY 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,SIALE and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: DATE: l <br /> PROPERTY/BUSINESS OWNER❑ ATOR/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, geoteclmical 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. PAYMFNT <br /> TYPE OF SERVICE REQUESTED: ,', RECEIVED <br /> COMMENTS: DEC 01 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> "AsSIGNEDTO: <br /> � <br /> 1�/a EMPLOYEE M DATE: I� <br /> ( EMPLOYEE M DATE:1Z 1d (if already completed): SERVICE CooE: P/E• Q 3 <br /> FeeAmount&L l 5V W Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />