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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business ol•Property FACILITY ID# SERVICE REQUEST# <br /> r <br /> PC,s�.0�rrla-) FAmmm��,ss Sc2mma��5y <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS® <br /> FACILITY NAME1J` I ` <br /> SITE ADDRESS l C (Y 1C�>1 � ma Y,l- ctk <br /> Street Number Direction Street Name CityZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �' G7 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT, APN# ELANDUSEPLICATION(A.c'i) S�S- -4 y4 <br /> PHONE#2 ExT. EMAIL OS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REAQUESTOR <br /> REQUESTOR1 �, /� t <br /> /l�•I�t �\�('�(J�� ` ` �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME C�}t l PHONE# l ExT. <br /> cQ <br /> HOME or MAILING DDRES FAX# <br /> CITY Y� STATE cp ZIP �' L' EMAIL 666 v -CO- <br /> BILLING <br /> O 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 /> 1 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 I BUSINESS OWNER❑ OPERATOR ANAGER� 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 < �or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SEP 0 7 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE: 9-7-23 <br /> ASSIGNED TO: Gehane Fahmy EMPLOYEE#: 8788 DATE: 9-7-23 <br /> Date Service Completed (if already completed): SERVICE CODE: 61 PIE: 1602 <br /> Fee Amount: 162 Amount Paid Payment Date (511-+12-5 <br /> Payment Type �W l Invoice# Check# Received By: <br /> payment 168399266 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03!22123 <br />