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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST '�'o 0 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S9-TQ)?)12a 1 <br /> O NER/OPERATOR <br /> - CHECK If BILLING ADDRESS <br /> ` <br /> � (A 6 <br /> luNAME <br /> SITE ADDRESS i 1 <br /> coVWIJ V <br /> Ly.. <br /> treet Number D1FectionWA et Nam • ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) J&4 I& ,j�. )� <br /> ee r , eet Name / <br /> T <br /> ,ZIP <br /> r�2-10 <br /> PH E#1 EXT. APN# LAND USE APPLICATION# <br /> (?E C90 0 9y <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE I i on zc&. �e z- CHECK if BILLING ADDRESS <br /> BUSINESS NAMExi <br /> 10- tJ <br /> H E ING A-WRESS ()� FAX# <br /> 17)y 4F ( ) <br /> CITE TR <br /> ZIP 52 // 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. A <br /> APPLICANT'S SIGNATURE: CJ7(r.. �. cu" 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 i formation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provi �°r my <br /> representative. CI`)" <br /> TYPE OF SERVICE REQUESTED; jL''U�JI'E FUu�J Co�stei ��+���►� �® <br /> COMMENTS: <br /> 102023 <br /> 1�oRONt N COUNTY <br /> AQjj <br /> HST H DESIV ZAL <br /> PAR MINT <br /> ACCEPTED BY: Lt EMPLOYEE#: DATE: <br /> ASSIGNED TO: `J\^, 1 'd G ��( EMPLOYEE#: DATE:1�, /%D\Z-_J <br /> Date Service Completed (if already completed): SERVICE CODE: (p P I E: \Ip(1)2 <br /> Fee Amount: Amount Pai ��� D� Payment Date <br /> Payment Type I� Invoice# Check# 170 J� L��lj Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />