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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C= FA (00z�0z3 3/2(APB 7 3,4 1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ACILNAME <br /> PTO t O5 � tle oencj!7S <br /> SITS AnnRESS <br /> S (' _ S L,�_ �� 1 <br /> Street Number Direction "'on Street Name City Zip Code <br /> HME Q Or MAILING ADDRESS (If Different from Site Address) <br /> L 3 Street Number Street Name <br /> CITY STATE ZIP <br /> Yu x'537 6: <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZOO 9`77— <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( 35 �8 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> U0 CQCHECK If BILLING ADDRESS <br /> BUSINESS NAMEc I PHONE# EXT. <br /> A Orb of, iCl(1 l L� 'j2CC�s 21� � <br /> �I_IO Or MAILING ADRII� FAX - _ �46'CCII?? ✓� 1 <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 d FE R laws. <br /> APPLICANT'S SIGNATURE:K DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 PAYMEwrr my <br /> representative. RECEIVED <br /> w <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A H-- 9 <br /> clt 1 2021— <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY EMPLOYEE#: 17A -3 DATE: 1 �? <br /> ASSIGNED TO: EMPLOYEE#: U g DATE: lJ <br /> Date Service Compl ted (if already completed): SERVICE CODE: PJ <br /> E: <br /> Fee Amount: 6,2— Amount Paid // of Payment Date j / <br /> Payment Type C �– Invoice# -- # �1 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />