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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICE REQUEST# <br /> r r <br /> �� sr 9K01Dg---+1t3 <br /> OWNER/OPERA OR <br /> f CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> k coin rn V� 1 <br /> SITE ADDRESS 116 /) / O ` 5 G`� y G� lo Z <br /> Street Number Direction V� 7 Street a e L Cit V ZipCode <br /> HOME Or MAILING ADDRESS (ifDifferent from Site Address) <br /> 7 D r• -e Number Street Name <br /> CITY STATE ZIP <br /> a 33 <br /> PHONE#t EXT• APN# LAND USE APPLICATION <br /> (20 <br /> rNE#2 EXT. AIL BCIS DISTRICT LOCATION CODE <br /> ) rito 5tee I <br /> CONTRACTOR / SERVI E RE TOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S E 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, Standard , STATE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z <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 provided to me or my <br /> representative. C �J <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 4116 <br /> U(j 5 <br /> tiCO <br /> EA(TH p PM�� 7Y <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: f f� ��(� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: O(D <br /> Fee Amount: _ Amount Pai 02 00 Payment Date ZS <br /> Payment Type �- Invoice# Check# �'79�� Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />