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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADORESS <br /> FACILITY NAME _ <br /> ITE ADDRESS <br /> OA Street Number Direction Street Name UGI �� Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY AWL`T` STATE � zip <br /> PHONE#j 1 V-� Ems' APN# LAND USE APPLICATION# <br /> PHONE Z ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr• <br /> ( <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOW DGEMENT: 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 drat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT and FP L laws. , r <br /> APPLICANT'S SIGNATURE: DATE: 11 11—J J17- <br /> PROPERTY <br /> /Z— <br /> PROPERTY/BUSINESS OWNER❑ /'OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> 1fAPPLICANT iS no!She BILLING PARTY proof of authorization t0 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: RECEIVED <br /> COMMENTS: NOV 15 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: JftA EMPLOYEE#: DATE: 1 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: l <br /> Fee Amount: I _ Amount Paid .lf l5 _ Payment Date 11 / 5i ]iv L 2— <br /> Payment <br /> Payment Type /r) Invoice# 15pea# 1 5 �?]S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1711003 <br />