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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT � O�2 9LIS3 <br /> SERVICE REQUEST <br /> Type of Busipessroperty FACILITY ID# SERVICE REQUEST# <br /> ,, SROOS7574- 11 <br /> OWNER/OPERATOR TA DD <br /> I q <br /> 6 1 s-s� CHECK If BILLING ADDRESS <br /> i <br /> FACILITY NAME <br /> SITE ADDRESS3� C C <br /> Street Number Direction y v `7 Street Name J J Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> O �. Street Number Street Name <br /> CITY STATE ZIP <br /> 7a-4:101t A q52 9S <br /> PHor #1� ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONT ACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 SIGNATUR� DAT <br /> r 42 <br /> PROPERTY/BUSINESS OWNE 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 Is provided to me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: AYA�/E <br /> COMMENTS: <br /> e c ll-Je- A ®EC 19 <br /> 1023 <br /> SAN JOAQVIN <br /> ENVIRONIU NOU n' <br /> HEALTH DEPART <br /> ACCEPTED By:----) EMPLOYEE#: `J J DATE: 9 <br /> ASSIGNED TO: EMPLOYEE#: Q Z� DATE: .L2-3 <br /> Date Service Completed (if already completed): SERVICE CODE: I' ( P 16, <br /> �1 9 <br /> Fee Amount: Amount Paid TIt Payment Date Zai 2-3 (JJ <br /> Payment Type Invoice# Check# )7 07705-6 Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />