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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/OPE A OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 'O <br /> SITE ADDRESS kA <br /> w f Z <br /> Street Number Direction t V1 Name I Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> a5� - L8R2 <br /> PHONE#2 Exr. EMAI BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQU TOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX III <br /> ( ) <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 the work t performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FED L law <br /> APPLICANT'S SIGNATUR DATE: V/1 A120 2-3 <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER THER AUTHORIZED AGENT ❑ <br /> /f APPLICA IS not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION T R LEASE 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 in the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provid <br /> representative. \i _•v I <br /> TYPE OF SERVICE REQUESTED: b� 1,L Fo-t/ con'5t v -GSL-bv) SF <br /> COMMENTS: a%JOA 3 <br /> H ilR <br /> 71if r <br /> ACCEPTED BY: EMPLOYEE#: DATE: f 114 12---3 <br /> ASSIGNED TO: ku+ _ _ _d,C�_ EMPLOYEE#: DATE: W1,412-3 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: '1162 ev Amount Paid Payment Date <br /> Payment Type /t Invoice# Ick# 8 I o�2� Recl ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> ai <br />