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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 51-00167 4- 18 <br /> OWNER/OPERATOR (Jt CHECKIf-BILLING DRESS❑ <br /> af <br /> FACILITY NAME n l-e /^ 7I`�� 1-74 co <br /> S SK► <br /> SITE ADDRESS :q H qL S An a pv i�AVcity95 a 0(a <br /> Street Number Direction Street Name Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE C� ZIP 2 7 / <br /> a� �C_ JJ �o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2vq) `I-41`) P-) <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (20 ) 02 - SIZ3 c((c Tq JCk,\ G n <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> w 7 �y <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 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: e DATE: �bZ.3 <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 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 IsN <br /> ded to me or my <br /> representative. ja <br /> TYPE OF SERVICE REQUESTED: r (�A V) ECEIV <br /> COMMENTS: l I p 1 A�C�1 �� 1 <br /> Iv` V vl QV 1013 <br /> SAN JOAQUIN CO <br /> HEALTH 1),,pAS <br /> ACCEPTED BY: v O nyu j�/� O r�n EMPLOYEE#: DATE: <br /> ASSIGNED TO: I z ` 1 , -Af a Z G� EMPLOYEE#: DATE: ��- t+- <br /> o�1 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 2 3 P/,E: I r„oc <br /> Fee Amount: Amount Paid L��/ r O Payment Date ' 2��j/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 �� 0 <br />