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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> X455ZCI 2 <br /> OWNER/OPERATO <br /> /j J'o ' I^ CHECK If BILLING ADDRESS <br /> FA a _NAMNe <br /> _ L i <br /> 1n� cy�, u�^� \C n 2 Seo ►� <br /> SITE TTES�, Street Number ���1 <br /> Direction \ . Street Name CIt , Zi Codc <br /> HOME or MAILING AD ESS If Different from Site Add res <br /> r Street Number Street Name f �\ <br /> CITY i\ \ STATE P L lJ <br /> PHON #1 l X11 E.T. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME \_ `�\( D �`^J� rYv PHON # <br /> HOME or MAILING ADDRESS (' l = y r^ V FAX# ) <br /> l4�"(r_ 1 IUB <br /> CITY t j v +1 S ATE 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, StandardsoSnd FEDERAL laws. , I ,� <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 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 o me or my <br /> representative. r M <br /> TYPE OF SERVICE REQUESTED: (L hCkY) -e OT GW Irl S1ti-I p SIVE <br /> COMMENTS: Cr 10 2023 <br /> SAN <br /> VIRON N COUN1Y <br /> HEALTH pS 4S/V'RT-t NT <br /> ACCEPTED BY: i\,A EMPLOYEE#: DATE:%(A\�(br2C11ZZ <br /> ASSIGNED TO: �. 6,l� 1 EMPLOYEE#: DATE:j(Dk 1QjI <br /> Date Service Completed (if already completed): SERVICE CODE: (p P/E: 0 SOO2 <br /> Fee Amount: r(02.(ZXO Amount Pai ( Payment Date <br /> Payment Type Invoice# Check# 17D r 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />