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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines or Pr erty FACILITY ID# SERVICE REQUEST# <br /> M ax) 500 �;ieo Gy <br /> OWNER/OPERATOR <br /> SCHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Sao <br /> 1 ► ,.SltreMet Name l�V\ �-C/ilt --�V Y ' ICCoJde <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number / v Street Name <br /> CITY . ST TE ZIP ( �] <br /> PH NE#1 ' �v ExT• APN# LAND USE APPLICATION# �/ll�2 <br /> vJ <br /> (70 H'7')0 to - ) Jo D6 <br /> PHONE#2Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> O mGi i 1M S <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO �` <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME r ` \ Pi NO)A 7 6 E <br /> HOME or MgIL.7,,&n ESst 1,�N'v,n 1`a 1/� FAX# <br /> CITY TO <br /> Z� 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 prepay d this a plication aM <br /> e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sta day S, S ATE and E <br /> APPLICANT'S SIGNATURE: DATE: �/ �✓ <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not tt e 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 7i,113J <br /> MAY 0 5 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:' EMPLOYEE#: ( ? DATE: IS 2-3 <br /> ASSIGNED TO: IV EMPLOYEE#: / DATE: <br /> Date Service Com ted (if already completed): SERVICE CODE: ` P I <br /> Fee Amount: 5(_ Amount Paid /. PaymentDate LS-- 2-� 2>-- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />