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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �S�ERRVICE REQUEST# <br /> ht C`lJU <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY <br /> Z SITE ADDRESS <br /> treet Number Direction Street Name City Zip Code <br /> OME r MAILING ADDRESS (If Different from Site Address) �' 2s'�.I O✓C��cz y, { <br /> Street Number Street Name <br /> CITY \ - STATE ZIP q c 3 <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Eur. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` , . ` \ PIKE_# ExT. <br /> HOME Or MAILING ADDRESS2�1, n FAX# <br /> CITY W` STATE ZIP �J1� 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: � (--e vt c� Rvi e A q DATE: 2 2 S <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�1i; �t�Q a or my <br /> representative. rr Ct <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JUN 16 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:j' _\ �`/ EMPLOYEE#: DATE: <br /> ASSIGNED TO: l EMPLOYEE#: DATE: <br /> � VC <br /> Date Service Completed (if already completed): SERVICE CODE: \ (''� PIE: <br /> Fee Amount: �� Amount Paid S� _ Payment Date <br /> Payment Type ?15 Invoice# C # 2J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />