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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 O ) 2,1-8-1-2- <br /> OWNER <br /> ,1-8-1-2OWNER/OPERATOR /l <br /> l�t w— �v (L/'cUZ CHECK if BILLING ADDRESS <br /> FACILITY NAME 1L" �2_ � �U C <br /> SITE ADDRESS 0 ri Vq +e <br /> Street NumberDlrection Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEC , f/ PH�7ONE# I _ y EXT. <br /> HOME or MAILING ADDRESS RESS` 1�' VC1 F lAx#� <br /> ��4- G('ZLi 5+e- <br /> CITY YA_ 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> l Z i� DATE: I , <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 assessmen information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pri or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: FTUV /�® <br /> COMMENTS: 1 i VV vVll X — C"_ SAN JO 4 23 <br /> 11EALT N De�M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I I -2——25 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: J LOO2 <br /> Fee Amount: l 2 Amount Paid I�2 r Payment Date 2[2- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />