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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Pi2 L)S N'9-4t�;ID <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR � <br /> LA1 I <br /> V l ( v 1 v G1 ctp <br /> Vt1 14ICK if BILLING ADDRESS <br /> FACILITY NAME Pr0cm ✓ <br /> W I 1 C' „j.F I <br /> ^� L <br /> SITE ADDRESS t♦�l 21 �'l A +i� <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) C1 31 �-�>`` <br /> Street Number ) Street Name <br /> CITY 1l' f� <br /> iLn0s V-1 STATE C^ Zip 6) -52- ( S <br /> PHONE#t APN# LAND USE APPLICATION# <br /> 3 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t�����G�� `���� �-�� 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. ENTw <br /> TYPE OF SERVICE REQUESTED: � V C (VA/ bAAA{-�l/t,s PA <br /> YM <br /> COMMENTS: Me NED <br /> Nov 17 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HM-rH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I _ Z3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ' <br /> Fee Amount: Amount Paid a Payment Date u J 2, <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />