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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 0 S� S CD <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME � �1 _ ` � � ( � <br /> SITE ADDRESSCy l L I S ZLI D <br /> Street Number Direction _ //scLree,�nl��� �� Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Lr 04 d1 n` ` <br /> ``Street Number �/ Street Name <br /> CITY Luck t STATE CA <br /> ZIP <br /> PHONE4" Exr. APN# LAND USE APPLICATION# `( <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ''ll ^f <br /> V 1 _ AW <br /> 7i� CHECK if BILLING ADDRESS <br /> BUSINESS NAME �}—� / V C _ , I /I^�/aj� S P N ;f r'b 1 �j �/ �EXT. <br /> HOME or MAILING ADDRESS, n q o;� �in a� FAx# <br /> CITY IM( STATE ZIP EMAIL <br /> V X15 Z�--(� <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 activityi <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: <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. A <br /> TYPE OF SERVICE REQUESTED: �u �� VI C�titu l "L� ; (�G titil1� sysc <br /> COMMENTS: Ov` IV <br /> U O <br /> �ogQ��N 2023 <br /> �lTjy�FpgRCO"14'V'), <br /> MFNT <br /> ACCEPTED BY: � EMPLOYEE#: DATE: 1 I� 20!Z3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: I <br /> Date Service Completed (if already completed): LL SERVICE CODE: (14� PIE: 0 <br /> Fee Amount: o. Amount Paid D� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />