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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6 d c Z(g R(oq G 2- <br /> OWNER/OPERATOR <br /> •I ` L`�� I CHECK If BILLING ADDRESS <br /> ` <br /> FACILITY NAME ` •7 <br /> W'\ <br /> SITE ADDRESS - <br /> Z0 5 =--C (O, 4 o cid <br /> Street Number DirSection Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ` <br /> 01I M A 5 a- J <br /> Street Number Street Narne <br /> CITY STATE ZIP ��� <br /> Lit v <br /> PHONE#') EXT• APN# LAND USE APPLICATION# <br /> (74 S o— ISS <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> I � \ CHECK If BILLING ADDRESS <br /> rAArA ` �0 <br /> BUSINESS NAME PHONE# EXT. <br /> elf 1 ( 8 6 ( 05 <br /> HOME or MAILING ADDRESSFAX# <br /> L It a q S c ) <br /> CITY SvISLvn 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. x <br /> APPLICANT'S SIGNATURE: �yJdd& ��j �, DATE: y 61A b/�-Ipl3 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANA ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY, /hoof of authorization t0 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 assessme . r ation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is pro I y <br /> representative. REQ` <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: lVp i v/ (�L�� S�LL L 1 'A'WJO <br /> C�(, �I/ ENV9 ONMENTAL <br /> hEASIITy;DEPART <br /> MENT <br /> ACCEPTED BY: // / A^ `2 EMPLOYEE#: DATE: <br /> ASSIGNED TO: / 6 !�( EMPLOYEE#: DATE: t)� 2- <br /> Date Service Completed (if already completed): SERVICE CODE: r,�� PIE: <br /> Fee Amount: cj Amount Paid Payment Date <br /> r <br /> Payment Type Invoice# Ghect2 2CI Received By: <br /> I TL <br /> EHD 48-02-025 SR FORM(Golden Rod)—, <br /> 03/22/23 <br />