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F12 D sw -► Z <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z3Ct <br /> OVPER/OPERATVON <br /> NI A_ r CHECK If BILLING ADDRESS <br /> FACIL 1T l l/ c 's .T� To C-to LLC <br /> SITE ADDS S iy�,I 4— M <br /> (, n��1lV VASt' r l I v' I <br /> Street Number Direction Street Name Cit Zip Code <br /> H E or MAILING DD SCS (If Di erent fr(ofj�1��Site Address) <br /> �� � V+"1- Street Number Street Name <br /> CIT'Q�T � ATE <br /> PRONE#1 U t KJ EXT. APN# LAND USE APPLICATION# <br /> . 00 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> G� CHECK If BILLING ADDRESS <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 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: <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 info.rpa-ti_on to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS provided l� my <br /> representative. ' <br /> TYPE OF SERVICE REQUESTED: j <br /> COMMENTS: %✓OA QVI 6 2023 <br /> Ely <br /> HE,q�H�qR��NIY <br /> ENT <br /> ACCEPTED BY: �CtVr A CS Lp EMPLOYEE#: DATE: _2L-2-3 <br /> ASSIGNED TO: C�Q4�-:� EMPLOYEE#: DATE: _2Z <br /> Date Service Completed (if already completed): SERVICE CODE: I P/E: /0 <br /> Fee Amount:��(02 ,QpQP Amount Paid � Payment Date r!� <br /> Payment Type (7k Invoice# Check# Recei d By:Z:: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />