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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST pR 0 5L1.i803 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME an <br /> lX <br /> SITE ADDRESS �� 0" /� S 4- <br /> Street Number Direction u Street Name �J T�Cit 1\ Zi 2 G Code <br /> HOME or MAILING ADD ESS (If Different from Site Address) 1 � <br /> Street Number Jeet Name <br /> CITY \- $TACE ZIP �,1 <br /> �/Ul lJ <br /> PHONE#'I ExT. APN# LAND USE APPLICATION# <br /> Q0 (-12 <br /> PHONE#T xT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME ,�A �„��o� PNONE# ` Ex-r. <br /> w 2 <br /> HOME or MAILING ADDRESS Qq d G FAX# <br /> CITYSTATE e ZIP EMAIL <br /> N/ S'^ <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: \ \2'\�-Z <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: R FN <br /> COMMENTS: eb <br /> �Pnv? 1 ?023 <br /> h EN�ROON COU <br /> �Cnyo���Ntr <br /> ACCEPTED BY: \\ EMPLOYEE#: DATE: <br /> ASSIGNED TO: C M v 0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 �[ t>\ P 1 E. <br /> Fee Amount: "Z Amount Paid db Payment Date 2( 2DJ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />