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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 50N 8-:1 13 y <br /> OWNER/OPERATOR ( <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME (n <br /> SITE ADDRESS <br /> '2() <br /> l=`( Street Number Direction Street Name Clt Zip 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 /> ( ) <br /> PHONE2 ExT. EMAIL . BOS DISTRICT LOCATION CODE <br /> � 9 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 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: '��� ez—t 111rct ex d GI DATE: <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 Is pro + a�te,�rZe or my <br /> representative. �1/I1ry�N <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 0 12023 <br /> '— SAIVjwRQUIN COVN7Y <br /> H�CTH DEPgR MINT <br /> 3ASSIACCEPTED BY: �':? eC EMPLOYEE#: DATE: J Z3 — <br /> ASSIGNED <br /> GNED TO: ' CJ> (I\ EMPLOYEE#: DATE: Ct <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z <br /> Fee Amount: Amount Paid -2.00 Payment Date R r <br /> Payment Type I Invoice# Check# Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />