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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��CDm223�S SRmmg�328 <br /> OWNER/OPERATOR ` <br /> A _ / ���,1M CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME dam[ ! 11 <br /> SITE ADDRESS �`A �,�t-yf( o o�� ���(��Z� v r,��� /(� <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( t ) CI C--L.�o�G L` <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P IC <br /> E <br /> HOME or MAILING ADDRESS FAX# <br /> 1 N) ';W' ( ) <br /> CITYN STATE U 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: DATE: IG( al J, <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. <br /> TYPE OF SERVICE REQUESTED: T�U,'C v Q t(C� 1." <br /> COMMENTS: <br /> 40"%Oct�y 202 <br /> FN OAQOAI 3 <br /> yE'9LTHROHM �OVN <br /> �Fp FNTAC <br /> ACCEPTED BY:JnA EMPLOYEE#: DATE: 'to Z�T <br /> ASSIGNED TO: EMPLOYEE#: DATE: Z <br /> Date Service Completed (if already completed): SERVICE CODE: r_ PIE: <br /> Fee Amount:< Amount Paid �� Payment Date /o/2q/23 <br /> • <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 r <br />