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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> LD LA q <br /> CUb <br /> OWNER / OPERATOR <br /> CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> SITE ADDRESS i(1 - 1-. CaA I�kV` � ._ �� C \ � I <br /> P j t / Street Number Direction Street Name Cityp Code <br /> HOME or MAILING ADDRESS ( If Different from Site_Address ) <br /> t I �_ - ✓�� � ' \ f�� Street Number Street Name <br /> CITY \ � STATE � . � ZIP <br /> PHONE # 'I ExT . APN # LAND USE APPLICATION # <br /> PHONE #2 EXT . EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> S 1k % r� CHECK If BILLING ADDRESS <br /> BUSINESS NAME , 1 V Y V PHONE # Exr . <br /> HOME or MAILING ADDRESS A FAX # <br /> vA <br /> CITY JC: r STATE t/� ZIP 2 �7 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 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 /> APPLICANT ' S SIGNATURE : moo. , r DATE : <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 it is pr ' s doto me or my <br /> representative . �� �� <br /> TYPE OF SERVICE REQUESTED : a ryl Eo rs V, <br /> COMMENTS : , 6 <br /> ) kv a ✓ �3 c �� c , c 0SAN� SANcoq <br /> �� ENV QUIN C <br /> ��4CTh�N�ENTq� � <br /> L Jati 7 1 �►+Vzvr <br /> ACCEPTED BY : ?jY �. �� (� \ . EMPLOYEE # : DATE , <br /> ASSIGNED TO : \f , � C� , � . EMPLOYEE # : DATE : I _ a �7 <br /> Date Service Completed ( if already completed ) , SERVICE CODE : ll} ls� I P / E : 't L <br /> Fee Amount : 'l (40 �L Amount Paid / r� � � Payment Date Z <br /> 27 <br /> Payment Type Invoice # Check # Received By : , <br /> EHD 48 -02 -025 SR FORM ( Golden Rod ) <br /> 03/22/23 <br />