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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type nofrBusiness or Prope ( FACILITY ID# SERVICE REQUEST# <br /> lv t�&) rtY �L SRO(Db-1?tt 15 <br /> OWNER/OPERATOR <br /> r O CHECK if BILLING ADDRESS <br /> FACILITY NAME �l <br /> SITE AD RES <br /> Street Number Direction r <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> til Street Number Street Name <br /> CITY STATE ZIP <br /> C' C <br /> PHONE#1 1 ExT. APN# LAND USE APPLICATION <br /> (C �) _l L1,St <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REOUESTOR <br /> REQUESTOR <br /> Q ti CHECK if BILLING ADDR SS <br /> BUSINESS NAME! PHONE# ExT. <br /> Gh► - - a <br /> HOME r MAILING ADDRESS FAX# <br /> COVII'llQ I ( ) <br /> CITYSTATE ZIP EMAIL <br /> L <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or busin ss 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 JOAOUIN <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 locatedt the above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment im � <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn as It IS available and at the Same time It IS pro {Q <br /> representative. i el <br /> TYPE OF SERVICE REQUESTED: p Aa ra Ch e cX SEP <br /> COMMENTS: SAN J <br /> OAQUIIy C <br /> HFALTyI�E w-r 1 iY <br /> FNT <br /> ACCEPTED BY: cc/V&A/uv' EMPLOYEE M DATE: q-27- <br /> -27- 23 <br /> ASSIGNED TO: k4,,�v1 EMPLOYEE M DATE: - 11 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P i E: 16 QpLI <br /> Fee Amount: Amount Paid 1�96 Payment Date .2--723 <br /> Payment TypeInvoice# Check# �� D S Receive By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />