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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cZ�3u� Sri uo3 o--3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME jl_, (� ^1 1 (� /IV 3'2gq-9 <br /> SITE ADDRESS +W2iV V I/�C'� 52(:�7 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> w n S Street Number Street Name <br /> CITY � STATE ^� ZIP �S <br /> PHONE#1 ExT• APN# LAND USE/APPLICATION# <br /> PHONE#2 Eur. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � -� rn 1i <br /> SCJ' l CHECK If BILLING ADDRESS <br /> BUSINESS NAME Exr. <br /> HOME or MAILING ADDRESS ll� � L�O AFI,A6X# <br /> S}- ( ) <br /> CITY LrA- f STATE 6f zlPgjs 3 3(`, 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 tion and that the k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard , STATE nd FEDERAL I S. <br /> APPLICANT'$SIGNATURE: t a " DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER d 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. PAY <br /> TYPE OF SERVICE REQUESTED: T;W REc;:IVED <br /> COMMENTS: MAY I an <br /> MAY 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L46 <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: mo <br /> PIE: <br /> Fee Amount: Amount Paid Payment Date S/SZ <br /> Payment Type Invoice# Check# �-C� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />