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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA(n2-4252 S9mm$-}ZZ 1 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS Ca\,Forna s4;jr ea.t <br /> Street Number Direction Street Name 't e City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Clll!) ck 5,\ r' Street Number Street Name <br /> CITY STATE ZIP <br /> C> c � UC-' (=A <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> (;tet) �t -�on( <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 pr M ` 0—) C-AF1 C7 CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> %-" WE C-3 Z3 L w`1 1 <br /> HOME or MAILING ADDRESS FAx# <br /> ITS D O cs�v G. S\1 R' <br /> CITY STATE �A ZIP r7�S2 \ EMAIL <br /> SAc�C CSC Un <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 <br /> APPLICANT'S SIGNATURE: �� L 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 provided t0r>;le or my <br /> representative. -*:41, <br /> TYPE OF SERVICE REQUESTED: C.l-�Cj.e p OL-3 htXS 0� 1 T <br /> COMMENTS: se O <br /> H��iR ^ro 20,;lly�FHq CO, <br /> N <br /> F <br /> ACCEPTED BY: 1 r.; - fie t EMPLOYEE#: DATE: C� a0 a3 <br /> ASSIGNED TO: r-3EMPLOYEE#: DATE: <br /> iCJC /) '1 oZ O o2 3 <br /> Date Service Completed (if already completed): SERVICE CODE: (o PIE: \.(o mZ <br /> Fee Amount: X1(02 Amount Paid /�� Uv Payment Date <br /> Payment Type Invoice# Check# ��� S�gb Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />