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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J rk C�X-�' sovos('06--A� <br /> OWNE /OPERATOR <br /> CHECK if BILLING ADDRESS <br /> rG � A <br /> FACILITY NAME <br /> SITE ADDRESS `jt/ �1/1L <br /> L/ Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> o � <br /> 3 k... �',� f' �L'. Street Number Street Name <br /> CITYSy �� STATE ZIP <br /> 7 / c� A <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 2ag 9 y <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^//A�D� <br /> CPA, <br /> A ' CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' �/` PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <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. �y <br /> APPLICANT'S SIGNATURE'�� DATE: v - % 2 <br /> PROPERTY I BUSINESS OWNER PERATOR/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 Zovlded to me or my <br /> representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: `V - /t+ A <br /> M APP 19 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: rJ t z <br /> DATE: 2— <br /> ASSIGNED TO: EMPLOYEE#: W!� DATE: J <br /> Date Service Complet d (if already completed): SERVICE CODE: I <br /> Fee Amount: �' Amount Paid l5� Payment Date ?] <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />