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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 7 I CHECK if BILLING ADDRESS <br /> FACILITY NAME nn <br /> SITE ADDRESS t CI 30� <br /> I. <br /> J 1C)o Street Number Direction reet Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) „, jc�t�t_ ��f«•` t���r <br /> Street Number Street Name <br /> CRY STATE` ZIPG <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> 61(, ) 233 -1153 <br /> PHONE#2 EXT. EM�A <br /> G1 IL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E'IT' <br /> ( <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP 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,STnlrErand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -,!/' DATE: S%/S � 23 <br /> PROPERTY/BUSINESS OWNER❑ OhRATOR/MANAGER 19 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 information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided t0 me Or my <br /> representative. <br /> PAYMENT- <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> MAY 0 8 2023 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: r\ <br /> / EMPLOYEE#: � c DATE: S . <br /> ASSIGNED TO: (\V—\ 'e EMPLOYEE#: "—i S8 9 DATE: S . �. <br /> Date Service Completed (if already completed): SERVICE CODE: V I PIE: 1 �Z <br /> Fee Amount: u , Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> kc� ' SR FORM(Golden Rod) <br /> 03/22/23 ?,- <br />