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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �A (Z do ?co('Oq� <br /> OWNER/OPERATOR <br /> -' ^ <br /> FA CHECK If BILLING ADDRESS <br /> _ /CILITY NAME v�l� < � � J� <br /> SITE ADDRESS <br /> , 1 T (� <br /> L- LAO Street Number Direction Street Name city de <br /> HOME or MAILING ADDRESS (If^Different from Site Address)� 4-15 <br /> 1 5��SZ-5L- "I I- � Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> ( 2r--? Stg <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> v161G1 6 0 ILA t' <br /> BUSINESS NAME1 11 PHONE# ExT. <br /> SGC L_� f1 5� (ZZ7, y?D~ !5l <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP 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: IN11Y16 ("p A44: Aj DATE: q- Zf- -?,o 2 <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 prPA3ft a Or my <br /> representative. �I�T E•i —T <br /> TYPE OF SERVICE REQUESTED: ED <br /> COMMENTS: APR 1 " awL` 9 <br /> 3 <br /> �fMAIG' WAIA OUNTY <br /> � W <br /> t vT, <br /> ACCEPTED BY: � �Gtii/1� EMPLOYEE#: DATE: /Z.f Z•3 <br /> ASSIGNED TO: J�i>Q EMPLOYEE#: DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid � Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />