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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ByLA z 5QW8�C6' <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> //I AL / /� <br /> SITE ADDRESS o I l/,lt� L)01'7z? <br /> fS�G 1/Y.�✓ Cy d J L B YE C� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 311,7 Street Number Street Name <br /> CITY 1 STA ZIP � —, <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (ti) 3 his <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C",! <br /> I_ � CHECK If BILLING ADDRESS <br /> BUSINESS NAME (� L�tJ PHONE III EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S ATE ZIP n r� /� 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: , 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 locatedt the above site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment 111�IQo the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It Is pr C �0 ! `tjR/I <br /> representative. F <br /> TYPE OF SERVICE REQUESTED: G'vn tO� <br /> COMMENTS: AN JO Q23 <br /> ENV/ 111/V <br /> N�LT/y�F M ry <br /> NT <br /> ACCEPTED BY:-6y tC nvl-C EMPLOYEE#: DATE: �( �C't l-2-Q) 3 <br /> ASSIGNED TO: � ;Ck- EMPLOYEE#:CI�j'4Gj DATE:(,(0t 1t t , '2,Q 23 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: ,t�� �Qj Amount Paid Payment Date 2L� <br /> Payment Type Invoice# CbaGk# D 2�lXl� Received ByENZ it, : <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />