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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FATT-2 cD3 SRmcD8�3m5 <br /> OWNER/OPERATO <br /> CV, ^ FOY <br /> HECK If BILLING ADDRESS <br /> FACILITY NAME )V- <br /> ,^ <br /> SITE ADDRESS(11�������//"v1�� �V` ��� <br /> �/""SheeZYJ�r r Direction Street Name �it Zi Code <br /> HOME MAILING ADDRESS (If Diff�ent from Site Address) <br /> Street...b. C Street Name <br /> CITY V \ STATE ZIP 2 <br /> PHONE#t ExT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> VCAl OCkV C� `nACffl <br /> \)CX /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME \� � V�` � v v 1.1 � PHONE# _ ExT.j <br /> HOME or MAILING ADDRESSFAX# l� <br /> ( ) <br /> CITY STAT 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❑ OPER MAN GER 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 asse ment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time itPAYWkfe or my <br /> representative. Is <br /> TYPE OF SERVICE REQUESTED: C1-Y 1Gk f)CJ e U f O W 11e Y S�19 <br /> COMMENTS: Z023 <br /> "AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:aC 1 G�Y�(�2 ��• EMPLOYEE#: DATE: 1(2)V <br /> ASSIGNED TO: EMPLOYEE#: DATE: \Q,1 <br /> Date Service Completed (if already completed): SERVICE CODE:(DC,, PIE: (olTi 2 <br /> Fee Amount:tt(02,(DCD Amount Paid l� 2.r- Payment Date IDI((-O[ 2 3 <br /> Payment Type C\n /I Invoice# - -34 f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />