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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> \ 0. <br /> SITE ADDRESS <br /> e C \ <br /> - - _ 0 �, _ _ I • <br /> 7 • Street Number Direction Street NamCit Zip Code <br /> llli <br /> HOME or <br /> MAILING ADDRESS ( If Different from Site Address ) t <br /> Street Number ` Street Name <br /> CITY $ ATE ZIP <br /> N� 1 5 <br /> PHONE # t ExT . APN # LAND USE APPLICATION # <br /> LA <br /> PHONE #2 ExT . EMAIL BOS DISTRICT LOCATION CODE <br /> G` ) C1 71) <br /> CONTRACTOR / SERVICE " QUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS AMEr ` PHONE # EXT . <br /> HOME or MAILING ADDRESS FAX # <br /> CITY \ _ y 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 . <br /> APPLICANT ' S SIGNATURE : 7 DATE : / C) / °Z <br /> PROPERTY I 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 Is prpkij to me or my <br /> representative . <br /> F E; <br /> TYPE OF SERVICE REQUESTED ; WAAv� <br /> COMMENTS : " tai <br /> SAN JOAGUI ,d COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : EMPLOYEE # : DATE : � � 2 <br /> ASSIGNED TO : / EMPLOYEE # : DATE : <br /> "I'll, .."Ift,"., ..7 xr <br /> Date Service Completed ( if already completed ) : SERVICE CODE : - PIE : 003i <br /> Fee Amount : (30 <br /> Amount Paid Ifl c-7 Payment Date 2 <br /> Payment TypeV Invoice # vnf of Received By: <br /> I Z <br /> EHD 48 - 02 -025 SR FORM ( Golden Rod ) <br /> 03/22 /23 <br />