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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST S SSI 8'9 Z <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .0 o S< c�o�-1 4-I 3 <br /> OWN R/OPER TOR 1 <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �^ n1 T l <br /> SITE ADDRESS _ / <br /> 9 Stre�e Z.ber Direction �� -T (treat Name / 15-6 ' Cit Zi Codc <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ) � — &. ) to <br /> PHONE ,_^ — xT� AIL ' d `�'� �9 F�� Il( TRtB� LOCATION CODE <br /> �7`�' `Jcn k t Il �' y \1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �. P ^' / ! f L� EXT. <br /> � tj'tJ <br /> HOME or MIT G ADDR ESS _ FAX# <br /> 1 1 ✓d I I <br /> CITY STATE 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 <br /> P'e'a Is a Ion an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Code andards, an s. _, J <br /> APPLICANT'S SIGNATURE: DATE: (� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof o 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. PAY <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: /�� NOV 30 2013 <br /> (} "^ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: r1 ( DATE: <br /> ASSIGNED TO: ��� EMPLOYEE#: !� DATE: <br /> Date Service Complet d (if already Completed): SERVICE CODE: PT E' <br /> Fee Amount: u- Amount Paid C� Z _ Payment Date (( j O L <br /> Payment Type Invoice# Check#Zg Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />