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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�o09�2 <br /> OWNER I OPERATOR n <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Z y y O S Gt\ V 0 vi <br /> Street Number 01on Street Name c1tv <br /> HOME Or MAILING ADDRESS (If Different from Site Address) £l <br /> �J Street Number Street Name <br /> CITY S1 O C � d STAop % <br /> PHONE#f Ezr• APN# LAND USE APPLICATION# <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME l/ PHONE# Ex'. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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 FEE RAL laws <br /> APPLICANT'S SIGNATURE: Clu4h ; �� DATE: 0 1 — / 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,f APPLICANT is not the B/LLING PARTY Proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of die property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available aniLpt the Same time it Is <br /> provided to me or my representative. �7A <br /> TYPE OF SERVICE REQUESTED: CE <br /> COMMENTS: <br /> 'MoN r Z 2023 <br /> H P IRONINCOUMY <br /> HI DEP"T NT <br /> ACCEPTEDBY: WcT�A EMPLOYEE#: I DATE: <br /> ASSIGNED TO: -ra, EMPLOYEE#: 7 DATE: 2 3 <br /> Date Service Completed (if already Completed): SERVICE CODE: 0(0 P I E: <br /> Fee Amount:i1510 1 <br /> Amount Paid 1L�- Q Payment Date ( �- 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�os1�H�(H S <br />