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f, p-3555 9 <br /> SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ON s ra rye' �D �G ( 1 5 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ^ I n I yl�Jt I TL �0(�DS n <br /> SITE ADDRESS I C1-(J1— UI N F—►9-0• 9F I ?,,f, 15 � <br /> Street Number Direction `� Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (%) S—+L�" ('o"1 5 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /E� r �C_0--M ( f ' <br /> `J C7r-A <br /> — � CHECK If BILLING ADDRESSO <br /> ST <br /> PHONE ExT, <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C STATE ! ZIP /a�, EMAIL tj A ti Ly�NT)>1 � yl� 7M <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned Jpf rloperty or business owner, operator ror 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 /> 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 FED RAL laws <br /> APPLICANT'S SIGNATURE: r DATE:OV <br /> PROPERTY/BUSINESS OWNER( I —UPEFANAGER ❑ 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 provided to me or my <br /> representative. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: R <br /> COMMENTS: App �I M <br /> SAN f J`OAQUINJCOUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: ( , 7� <br /> ASSIGNED TO: L � r P EMPLOYEE#: y S 1 DATE: '-4 , ` 3. 23 <br /> Date Service Completed (if already completed): SERVICE CODE: V I P/E: 1 btu Z <br /> Fee Amount: 1 S Amount Paid f 5 Payment Date '4 . 12 - 23 <br /> Payment Type Ul Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) .. <br /> 03/22/23 <br />