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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> • kown. <br /> OWNER OPERAT0 <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SIT ADDRESS l <br /> / Street Number Direction 7 ��eet ."'R—1 <br /> HOME or MAILING ADDRESS (If Different from SS;e Address) I <br /> Street Number \ Street Name <br /> CITY STATE ZIP <br /> PHONE##1 EXT. APN# LAND USE APPLICATION# <br /> 110 + J!I l <br /> PHONE#2 EXr. EMAILBOS DISTRICT LOCATION CODE <br /> ( ) /O u <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 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 tbg work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDER <br /> APPLICANT'S SIGNATURE: ;7 DATE: <br /> PROPERTY/BUSINESS OWNER I1h OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 11 r <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 ' <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment inform VED <br /> MENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 <br /> representative. AUG Tt q <br /> TYPE OF SERVICE REQUESTED: / � V �� 2U23 <br /> COMMENTS: r - - A „ JOAQUIN OUNTY <br /> ENVIRONM NTAL <br /> jj r H� TF EP T ENT <br /> f6 IF <br /> Y© � VJ/ t ►� <br /> ACCEPTED BY: EMPLOYEE#: DATE: ' Z� <br /> ASSIGNED TO: EMPLOYEE#: r/� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: O <br /> A__ <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />