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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (7)2-12(2 2 QZ8-36--s <br /> OWNER/OPERATOR _ <br /> V 7p C) � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME � ' <br /> L) <br /> SITE ADDRESS ,�7GG7 77HHls'fao� <br /> S �tNuinber Direction Street Name t �� ` C� Zi�ode� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number F Street Name <br /> CITY STATE zip <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> SO — c <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O Y1 � — �� _ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO JE ExT. <br /> 5 �� Sa _6 <br /> HOME or MAILING ADDRESS FAX# <br /> oCk anK A ( ) <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. <br /> APPLICANT'S SIGNATURE: L' al"c' 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 inef ation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provil �QJ,lily <br /> representative. Ren ••IC�/6Ii <br /> TYPE OF SERVICE REQUESTED: AM,, `O <br /> COMMENTS: !t l / ./ \�D Oq ZQ <br /> ,,R Q�IN ?3 <br /> Ny, M N <br /> ACCEPTED BY: I EMPLOYEE#: DATE: <br /> ASSIGNED TO: r EMPLOYEE#: DATE: 1 2 <br /> Date Service Compl d (if already complet d . SERVICE CODE: P I E:'l W& <br /> Fee Amount: $I Amount Pa• 2 bQ Payment Date �3 <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />