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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -00 CI --/Y() ( k S C)l7g�lS5� <br /> OWNER/OPER T R <br /> ^'e- CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME r <br /> a o r r ,, Tneitiefia <br /> ITEADDRES �,�Y"�`� <br /> e <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �"u �' 4' S s <br /> 2 ( Street Number Street Name <br /> CITY {n J STATE ZIP <br /> r <br /> Cl,-4 2 ? Ca <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) <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 /> Jot bJcA'r I a 5no ti ti IQ S � `l <br /> HOME or MAILING ADDRESS FAX# <br /> 171 <br /> CITY C,&-01 , U STATE C-C� ZIP � Z Z� 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 applicaylory and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA F-ED RAL laws. <br /> APPLICANT'S SIGNATURE: DATE:�� <br /> PROPERTY/BUSINESS OWNER Lti OP ATOR/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 infLvxw the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provide? <br /> representative. /J R <br /> TYPE OF SERVICE REQUESTED: M FF O l Lfl o f <br /> COMMENTS: HF,Fq� <br /> 2023Sqy JOgNQUIN lry�� rNT <br /> ACCEPTED BY: L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already com eted): SERVICE CODE: r�f n \ PIE: <br /> Fee Amount: \ � Amount Paid 2 ,r Payment Date , 2 2.Z 23 <br /> Payment Type Invoice# �� I 3L. ('o I Received By: <br /> EHD 48-02-025 SR FORM(Gold Ro ) <br /> 03/22/23 <br />