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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F,IX 2(oo/8 3RM8G(?8'0 <br /> OWNER/OPERATOR C',1,,� ..f J�` /I �� <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME /L (/I- r „ (9 V p <br /> SITE ADDRESS 'tl t I I ( irt� <br /> Street Number Di ection treat Na Cit ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9'-Z-2-3 /� <br /> Street Number C(An<1 k_ (-OV tName <br /> CITY STATE CZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> �)ij, Z- IZ),'1- <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR5 C�� J / ZA <br /> (� 7 r/, CHECK if BILLING ADDRESS 1:3 <br /> BUSINESS NAME &I (HONE# 2 EXT• <br /> HOME or MAILING ADDRES L� FAX# <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 applictanE <br /> that t w rk t0 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA RAL ws <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 provide to me Or my <br /> representative. cc <br /> TYPE OF SERVICE REQUESTED: CC <br /> COMMENTS: P ' <br /> �M 4N ?3 <br /> ACCEPTED BY: ��Z? � � EMPLOYEE#: DATE: '4 12-4 12 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: m�I P I E: , 3 <br /> Fee Amount:Y/& 2 Amount Paid (Q 2Payment Date 2 2� <br /> Payment Type Invoice# gheek-fF� t ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />