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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SQ0127138 <br /> OWNER/OPERATOR / CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS Li Alb <br /> So S '1 Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6 Ca t bL"- <br /> 75 <br /> • r <br /> Street Number Street Name <br /> CITY STAT ZIP <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> ( `715- `7q <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If ILLINGADDRESS11 <br /> S <br /> BUSINESS NAME PHONE# EXT. <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 w k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDER laws. q� <br /> APPLICANT'S SIGNATURE: �� DATE: J <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 prQi(Ided to me or my <br /> representative. ('+ Y <br /> TYPE OF SERVICE REQUESTED: e- CE�V <br /> COMMENTS: SEP 052023 <br /> SAN elvViRO <br /> N NOUN�?' <br /> kEgLTH 17E�T � <br /> T <br /> ACCEPTED BY: \J a z EMPLOYEE#: DATE: 3 <br /> ASSIGNED TO: I R I,,o 7— EMPLOYEE#: DATE: C1 55 J 3 <br /> Date Service Completed (if already completed): q 5 3 SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid Payment Date q <br /> Payment Type Invoice# c # � ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />