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t�osy �sg� <br /> SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f 4 lD Z(p2-11 G9,m 'foGq-- <br /> OWNER/OPERATOR e ly'I V'�" � 'P3 u_ I a'Y^ ^(J'0,S�� l CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1+A0 r port ( ,AAO <br /> Street Number Direction Street Name �J Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6102 I 0�.� S� <br /> Street Number Street Name <br /> CITY G '� STATE CA ZIP-T- <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ..7 �( C-1 n 0 S <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME be; ry r cx� en � n P� EXT• <br /> HOME or MAILING ADDRESS f� I'�0`u�4 Z I0-J`/,wt [_ L_ FAX# <br /> t'f �J (.l,T ( ) <br /> CITY v STATE />d ZIP DI 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 F RAL laws. <br /> APPLICANT'$SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT R/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 provided�p my <br /> representative. 1 n G 11—' ENS' <br /> TYPE OF SERVICE REQUESTED: T;-)pJ <br /> COMMENTS: JUL Z 6 202 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTry <br /> HEALTH DEPART E 7- <br /> ACCEPTED <br /> ACCEPTED B EMPLOYEE#: DATE: - 2rj -zv <br /> ASSIGNED TO: EMPLOYEE#: DATE: r� <br /> Date Service dompleted (if already completed): SERVICE CODE: 1 PIE: <br /> Fee Amount: / Amount Pa i /6� Payment Date 712& Z3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> IS <br />