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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST wdSq a19(a <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> rA m Fs (1)E,q--17D 9 9 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> t<• S <br /> FACILITY NAME T V l <br /> SITE ADDRESS , , r /V1CSL d 953-111 <br /> Strtdee <br /> et Number Direction �/V �� �� t me C City <br /> it Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> f ( '(\G Street Number Street Name <br /> CITY STATE ZIP <br /> 9 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (2-C? 9 0 1/I <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> '`A� \41 � CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME l�` /� I / PHONE# EXT. <br /> HOME or MAILING ADDR S FAX# <br /> s � fa yn� C-T ( ) <br /> CITY e�C C.4 TATE ZIP 9634/ EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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❑ 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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment inipfirliation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provi r my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C1 Y)C�0CJ Z C,( O W V�eV�I�1 t ^/ rr%- <br /> COMMENTS: $ <br /> H ROHiN CO <br /> TyOF�yFHT��, <br /> 'qRT,yENT <br /> ACCEPTED BY:"ip,Y 1C.,,IY,t' �t EMPLOYEE#: DATE: <br /> ASSIGNEDTO: V-adeCknne. L. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:( P/E: <br /> Fee Amount: \\n2 Amount Paid Payment Date j --4 23 <br /> Payment Type Invoice# F� D� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />