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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PRO IUS211(0 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � F t= ��t�� 3 8 SR([)P,-j 5`5 T <br /> OWNER/OPERATOR f If <br /> o � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> co Tr Lx�v' <br /> SITE ADDRESS rLo�l� f PCN' Vl ACL S � o <br /> 20K( 10 t"(Po�zv Y <br /> 5 t Street Numder Direction Street Name CiV Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 13 0E U o�_VA" n C J✓. Street Number Street Name <br /> CITY � STATE ZIP <br /> c <br /> JCvrt. cv1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (% gST- zq b <br /> PHONE#T E)cT• EMAIL BOS DISTRICT LOCATION CODE <br /> (6 sem) y - I5'��-3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS �j FAX# <br /> /7-S <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 a ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards TAT an EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PER T R/M AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT iS not the'Bl NG Ty proof of authorization to sign is required Title <br /> r <br /> AUTHORIZATION TO RELEASE IN MATION: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 info t'on to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It Is providt t y� <br /> representative. •/�`F -•acN <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JO <br /> 023 <br /> H,NV/ pN <br /> R ,cou <br /> H pEPAR M 1Vr <br /> ACCEPTED BY: EMPLOYEE#: DATE: (2-12— 1 ZS <br /> ASSIGNED TO: L1� EMPLOYEE#: DATE: 1 •Z Z 1 Z <br /> Date Service Complete (if already completed)---"'. SERVICE CODE: 06 P/E: <br /> Fee Amount: b 2 Amount Pai i d� Payment Date 1 <br /> Payment Type ` ('—f Invoice# Check# 1737 04W Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod}' <br /> 03/22/23 Il/\) <br />