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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TBusinessQ �or�roperty FACILITY ID# <br /> EES �VIC REQ4E,ST�#�� <br /> OWNER/OPERATOR CHECK <br /> ifpJ� ING ADDR. <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME l---0— ry p VA �'/O V1 e (�'• <br /> SITE ADDRESS ^2 3� o / _ /�.` / � �y d-- "�O C k.� �) Zo <br /> Street Number Direction �'T-K� bfi" • Street Name CI ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> v Street Number Street Name <br /> CITY ~ STATE ZIP (J, <br /> r. <br /> PHONE#t ERP. APN# LAND USE APPLICATION# l <br /> (2,C) ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> \ CHECK If BILLING ADDRESS <br /> BUSINESS NAMEml <br /> �.^ PHONE# Ems. <br /> HOME or MAILING ADDRESS .�0 "� 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,STA d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: a Z <br /> PROPERTY/BUSINESS OWNER❑ QWRATOR/MANAGER ❑ OTHER AUTHOm2ED AGENT❑ <br /> IJ'APPt/CANT 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 <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 and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> JAN 3 0 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 2�r DATE: ` �7 <br /> ASSIGNED TO: C J,I PL YEE M DATE: <br /> Date Service Complete (if already completed): Wr SERVICE CODE: P/E: p2 <br /> Fee Amount: / Amount Paid ( _ Payment Date 17307 <br /> AL3 <br /> Payment Type V(S Invoice# PtCc-k#15-6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />