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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Asi\on jhpo\/2-nd <br /> OWNER/OPERATOR <br /> f - -- CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESStreet YV wn\ 3 O ISe- AVe <br /> Number / <br /> (9 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 4tre t Name <br /> CITY STATE zip <br /> PHONE#1 J EXT. APN# LAND USE APPLICATION# <br /> (�D d=oll <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /tived� ' CHECK If BILLING ADDRESSO <br /> BUSINESS NAME PHONE EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY /: STATE zip <br /> BILLING ACKNOWLEDGEMEN!/T:: 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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: 4:2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZFD AGENT❑ <br /> IfAPPLiCANT 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ArrM <br /> TYPE OF SERVICE REQUESTED: vprl <br /> COMMENTS: OEr 0 8 2023 <br /> SM <br /> pAQ RO�IN ;0UN7Y <br /> HST H pE NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: C EMPLOYEE#: DATE: %'Z �� <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: U V <br /> Fee Amount: Amount Paid (�2 �' Payment Date ("21512-3 <br /> Payment Type Invoice# Check# O Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 5" <br />