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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�� d q- Z�4 FA W 21 z-t a SlRWg--ems <br /> OWNER/ ERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY N M ` <br /> r r Ce jt 21 a <br /> SITE ADDRESS Lit <br /> )mel- <br /> r <br /> Street Number Direction r` N I (�treet N\a/me I V (� Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Number T StreeAN-±�- <br /> CITY�/_ STATE ZIP , <br /> PHONE#1ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <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 DATE: D 1 <br /> PROPERTY/BUSINESS OWNER OP ATOR/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 � to me or my <br /> representative. Ai <br /> TYPE OF SERVICE REQUESTED: FAV <br /> COMMENTS: <br /> N 10 ?0?4 <br /> S NV/RQu/ty COU ry <br /> HFACTH pFpAR NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 <br /> 2-4 <br /> ASSIGNED TO: EMPLOYEE#: DATE: V 10 <br /> L <br /> Date Service Co leted (if already completed): SERVICE CODE: I E: <br /> Fee Amount: Amount Pall / =P— <br /> Payment <br /> ayment Date Z <br /> • <br /> Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> p� 0 22 <br />