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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAT 1-4(P4 IT, <br /> OWNER/OPERATOR <br /> /1 CHECK If BILLING ADDRESS <br /> 6 1 Cr CI ��tC� <br /> FACILITY NAME,-- <br /> I <br /> I <br /> h 6 0, <br /> SITE ADDRESS U le U'n% -1 �- 7"",-I L✓N <br /> �5'3ZU <br /> 1 z o57Street Number Direction Street Name CRY Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Q F 4ve Street Number Street Name <br /> CITY STATE ZIP <br /> Som e T--,'-,r CA ab IS p <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> r CHECK If BILLING ADDRESS <br /> BUSINESS NAMEo PHONE# EXT. <br /> �Gl� G �' `� 1 t C ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY f S \CY STATE C ZIP 3 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: DATE: 5) )b Z 3 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 <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: �a <br /> MAR 10 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: �Z�3 DATE: 3110/ 7-5 <br /> ASSIGNED TO: EMPLOYEE#: Q �� DATE: 3 1 0 �3 <br /> Date Service Comp et (if already complete¢ : SERVICE CODE: /_ P Z: <br /> 16� <br /> Fee Amount: Amount Paid L S� Payment Date ?J ` 1 <br /> 2,0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17!2003 5 <br />