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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 1`/�\`n •`I , � CHHEE <br /> CK If BILLING ADDRESS❑ <br /> FACILITY NAME V 1 v <br /> SITE ADDRESS j „ <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or M ILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYS�(')C ^ STATE ZIP <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> (L\0L tk�`') <br /> PHONE#2 Exr• EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> i1 ,( <br /> BUSINESS NAME PHONE# EXT. <br /> S a d V1 O vox` \Gduc <br /> HOME O MAILING ADDRESS Fax# <br /> Q C ( ) <br /> CITY STAT 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: �� 1i� �� 7 DATE: <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 prQJed to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: e X11 cu `0 SKG' <br /> COMMENTS: MAY v <br /> 1 p <br /> I 2023 <br /> UN EA RONIyeNT,q NTM <br /> DEP�TMENT <br /> ACCEPTED BY: v }� � EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� • ` ` ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE:11 It I <br /> Fee Amount: �SI/1 Amount Paid Payment Date \5 p 2 <br /> �L a J <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />