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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST (fie")- (SCP Q- &-l-1, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> g <br /> OW /OPERATO <br /> ��� � �� <�� � CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 CSV C�) <br /> SITE ADDRESS �— J {— n r C/� <br /> "( I reet Number Direction Street Name City Zi Code <br /> Hom&DrMAILNJ_ARES (If Different from Site Addres�) ( �_ C rA <br /> c �./�" et Number CC i SFttreet Name <br /> CITY STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TE n FEDERAL laws. <br /> APPLICANT'S SIGNATURE??� DATE <br /> PROPERTY/BUSINESS OWNERP-- TOR/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 isPA',yided to me or my <br /> representative. All H <br /> TYPE OF SERVICE REQUESTED: l� <br /> COMMENTS: h� r �y ,�,• Nov 20 2023 <br /> 'v l l (� �•` 1 SAN U <br /> N ENVIAQNM CDU �, <br /> FACTy pEPAR MENT <br /> ACCEPTED BY: EMPLOYEE#: �,f DATE: ,Z-3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: I L 20 112 3 <br /> Date Service Comp ted (if already completed): SERVICE CODE: \ P 1 E: 03 <br /> Fee Amount: Amount Pai �c.o�-Ov Payment Date 11 <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 Y --� <br />