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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l7rinks � -152 j'Z(n (a('CD <br /> OWNER/OPERATOR <br /> v CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS jQ j 2 �a/ �pG� fUYI �%5 Z/5 <br /> Street Number Direction Street Name rt City 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 /> C-0,j) `fy- X23 s <br /> [PHONE#Z ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 42U V(/ CHECK if BILLING ADDRESS <br /> BUSINESS NAME t PHONE# ExT. <br /> HOME or MAILING ADDRESS I i FAX# <br /> CITY STATE I, ZIP EMAIL <br /> D <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: G/` 2 Cr' 2_ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT�isot 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 proVld to me or my <br /> representative. A <br /> TYPE OF SERVICE REQUESTED: LAJ �.1,`-��,/ CcNL-S <br /> COMMENTS: 4P <br /> SAN <br /> hEURO Utl y COU <br /> E9CTy0� N�NT <br /> ACCEPTED BY: V W EMPLOYEE#: DATE: <br /> ASSIGNED TO: ���Q b EMPLOYEE#: DATE: Z-t- 7 <br /> z�j7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check#, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />