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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FA 0 mm 3i 12 <br /> OWNER / OPERATOR <br /> r CHECK if BILLING ADDRESS O <br /> FACILITY NAME i <br /> _ C'ZY " n 'r L11'1� I'1� <br /> SITE ADDRESS <br /> Street Number Olrectlon lJ1 Street me City i ' <br /> Na <br /> HOME or MAILING ADDRESS (If Different from Site Address) C r <br /> RE <br /> CE <br /> Number Street Name EUEI <br /> D <br /> CRY STATE ZIP <br /> ExT. APN # LAND USE APPLICATION # NOV23 <br /> PH��O``NE #1 SAN JOAQUIN C <br /> ENV �� TY <br /> PHONE #2 ExT. EMAIL <br /> ff FBOISDISTRICTfIcTill nV6I RT ENT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1v ` PHONE # Exr. <br /> HOME or MAILING ADDRESS FAX # <br /> ZIP EMAIL <br /> STATE V <br /> CITY ���� , � -� L�-.�'-s �,1� C t�- 2, <br /> BILLING <br /> •�'� <br /> BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator o authorized agernr oTartTe,��m <br /> . . .. _ . <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 /> APPLICANTS SIGNATURE : DATE : eD r ' � <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT P <br /> if APPLICANT Is not the BILLING PARTY, proof of authorization f0 sign is required Title ice/" <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 to me or my <br /> representative . <br /> TYPE OF SERVICE REQUESTED : u S T ( Cf 1 _f <br /> COMMENTS: , <br /> 1�VflY k p rear � v t t o I C c r1 ,u r i d r+� t Allo l (i 0 r� r <br /> ^ACCEPTED BY : S - t �+ ` }� EMPLOYEE # : DATE : 2 � <br /> ASSIGNED TO : C 01ro l p� , rS - ..� EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE: J47/ � � 7 Si P / E: 2� C) <br /> �> Fee Amount: L` 4 4 � Amount Pa fl ?20 OD Payment Date 1 <br /> Payment Type C/ Invoice # Check # 744 73 e4 74e 7 Received By: <br /> f7zu 1Le -fv C1o��-+fin a C _ <br /> EHD4&02-025 �(irU Qc-i'� Gt , V ' apP e� SR FORM (Golden Rod ) <br /> 03/22/23 1 <br />