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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> i D a5 $ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS® <br /> F CILITY NAME / <br /> SITE ADDRESSt <br /> Street Number D Ian 1 Stre¢t Name Cit 7J Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> ITV STATE zip <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> Vel) 32 '� -39 7 <br /> PHONEIYL Ezr• BOS DISTRICT LOCATION CODE <br /> (Zo() 2�-Qi0 <br /> Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex . <br /> HOME or MAILING ADDRESS FAX# <br /> CITY LG•C\ I STATE / zip �-Z <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: y� /}� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHOmzEo AGENT❑ <br /> IfAPPLICAM'is not the BILL/NG 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 a'r <br /> �p%)f MM is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: FEB 0 2 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> C �q, e awn�r-AIP iNsfcf-C-JiGu) <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: -2- <br /> ASSIGNED <br /> 2ASSIGNED TO: 11 fthLA <br /> EMPLOYEE#: DATE: '� 23 <br /> Date Service Completed (if already com eted): SERVICE CODE: 1 P I E: I hOL <br /> Fee Amount: Amount Paid Payment Date 2 Z 2,t) 2- <br /> Payment <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />