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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5R3(2)$-7a-7 cP <br /> OWN R/OP TOR <br /> ` CHECK if BILLING ADDRESS <br /> O <br /> FACILITY NAME <br /> �c'c1S <br /> oSITE DRES C C <br /> Q treet Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Di Brent from Site Address) <br /> 6 Street Number Street Name <br /> CITY STATE ZIP <br /> f N <br /> PHONETI f EXT. APN# LAND USE APPLICATION# <br /> �) / <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 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. 2 <br /> APPLICANT'S SIGNATURE: majiv, Li bn CjO� 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 t0 me or my <br /> representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: /N) OF 1 0 6 2023 <br /> vv �� �� SAN JlOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: V lX <br /> Date Service Co leted (if already completed): SERVICE CODE: P E: <br /> Fee Amount: I Amount Paid I Z Payment Date 2 3 <br /> Payment Type G tie C Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />