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Ilk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T-R 0002-ICS(� OD 1--y �K2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS [--10':5 <br /> '0� �- n/ • ,�!(C��'�"1 ll lil+T V`�✓ ��'\ �1 S Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 0 C,<\__Y\ <br /> C p Street Number Street Name <br /> CITY STATE ZIP <br /> qs <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (S5y) 1SS yAr�'� <br /> PHONE#2 Eur. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS AMC\E PHONE# EXT. <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: `y` ��Vyut;VLji,, DATE: 1 / 3 <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 provided to me Or my <br /> representative. r (— <br /> TYPE OF SERVICE REQUESTED: 1 C I�VL`JLt -A"Cfvl t- �IV^ <br /> COMMENTS: V V 1a Y W`Q C..F� �' 'Y � 1016C ® �Ct' <br /> 1 0 <br /> O2E <br /> N �ROEOEALH NM �NryDEpgRAL <br /> ACCEPTED BY: I EMPLOYEE#: DATE: t7 I 23 <br /> ASSIGNED TO: C VVA- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: U L <br /> . u Fee Amount: , Amount Paid /� d� Payment Date ' 23 <br /> Payment Type - Invoice# Check# 12 2-S3 1 J OL) I <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />