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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PR052-00r Id <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/iOPERATOR c <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ` I,�('• 5 V � If <br /> S <br /> 44 LAI <br /> SIT DDRESS � V Ihnr ,r S-49(O+-Tq lv G�S2D5 <br /> n Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> /1 , Street Number Street Name <br /> CITY �q O STATE ZIP <br /> PHONE#1 /L, EXT• APN# LAND USE APPLICATION# <br /> Sy <br /> PHONE#2 , ExT• EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> �' V�l I (— PHONE# EXT <br /> c V\ ( ,9u6 - �� ? <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY ' / 4 me ST E ZIP / EMAIL <br /> BILLING ACKNOWLE GEMENT: 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. C <br /> APPLICANT'S SIGNATURE: lj�. 1/L�" \ DATE: I l <br /> T� <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 information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time IMS prOV10C�t� e or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: CV--, ACJ e OV C)COrle.0 Sit0 <br /> COMMENTS: <br /> �OA ?OZ3 <br /> H O V/N CO <br /> UV <br /> pA��44 7Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: lZ`5 1 Z3 <br /> �<lav�re iti-1 <br /> ASSIGNED TO: �C�u�;C` �( EMPLOYEE#: DATE: 12`15123 <br /> Date Service Completed (if already completed): SERVICE CODE: �(L` P I E: (o m3 <br /> Fee Amount: 1t�2 czc' I <br /> Amount Paid /6; ,no Payment Date /4�4� <br /> Payment Type exejI Invoice# Check# 72- 7 72LSS- Received By:mr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 3 <br />