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nee&/2- P�2- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O /OPERAT R <br /> i CHECK if BILLING ADDRESS O <br /> 5ae U e-SI <br /> FACILITY NAME ()— � �'�[ I 1 <br /> SITE ADDRESS ('�/+ <br /> L O Street Number Direction I tFeet Namr Cit � 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 /> zr > Z <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE R <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P N `_� " ExT. <br /> o <br /> HOME Or MAILING ADDRESS�(( FAx# 7 V <br /> CITY DATE ZIP <br /> TEMAIL <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 F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: O J " ZZ -Z <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 assessmeP,;jrd <br /> to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is � 4 "'4rmy <br /> representative. 1� ' <br /> TYPE OF SERVICE REQUESTED: ' JQ,I/l( 1/� MAY <br /> COMMENTS: `RQUIty CUM <br /> 7}f�Da pt��NTM <br /> ACCEPTED BY: Y'/� _ EMPLOYEE#: DATE:Co ZZ 2- <br /> ASSIGNED <br /> ASSIGNED TO: �a�� Tne EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Vl� PIE: I U 7 <br /> Fee Amount: _ Amount Paid Payment Date 5 11 C112— <br /> Payment <br /> 2Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 Z5 <br />