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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e i o c� S''mCD 8-+`I t 9 <br /> OWNER/OPERATOR <br /> � � O � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME j 0S COM P 11 <br /> SITEADDRESS2g3Z V U l,( U0��'�\Y <br /> (k\`L 5 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -' 3"- , , on cU r <br /> I �(�'1 r S Street Number Street Name <br /> CITY STATE C A ZIP (45ZC6 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> Q09)981-3 2 SG <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Ja = �, <br /> BUSINESS NAME J �L �O� �r PHONE# Exr. <br /> HOME Or MAILING ADDRESSnIIO��'GlY S� FAx# <br /> CITY �j�0 0� STATE C ZIP g5ec C EMAIL/ _•1 \JyN <br /> I v J lY V.� ON^ <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, Standar s,,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��, h(/�\ j��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 information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided to me Or my <br /> representative. P <br /> TYPE OF SERVICE REQUESTED: P-1 rn CC <br /> COMMENTS: V NO <br /> y Y <br /> sAN JOAQ <br /> N�M/i DO pk'TZ' AtN <br /> MFNT <br /> ACCEPTED BY: f�q EMPLOYEE#: C� DATE: /f J <br /> J <br /> ASSIGNED TO: " EMPLOYEE#: lC DATE: /i i � <br /> Date Service Compl to (if already completed): SERVICECC,ODE: P E: O <br /> Fee Amount: l Amount Pa' ��� �U Payment Date f 23 <br /> Payment Type 0 � Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />