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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR0sgolu3 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -� 5 so <br /> O R/OPERATO <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ?y- ' <br /> SITE ADDRESS L `� YY 1 E 4 S fi rw e b 4 A�/e(�Ue s-fiO c k TC h ��Pc (zoz <br /> ,.Street Number Direction Street Name cityI/ 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) W c b to j^ ,( V ,57"o C-k �O {� <br /> I v `� Street Number rC Street Name `� C�G <br /> CITY STATE ZIP <br /> L <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) y� q I0-�-q <br /> PHONE#2 E)cr. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM (HONE# EXT• <br /> I c �( <br /> HOM O MAILING ADDRESS I / FAX# <br /> CITY STGC_ T4Z4 E o STATE ZIP 5 �z C� ,G HjQ/D.. $2 nil •FYI <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: 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 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 IsYA <br /> ded to me or my <br /> representative. t ' Y <br /> TYPE OF SERVICE REQUESTED: C�00 U� ��li�r.YSY�4 : CES <br /> COMMENTS: JAN 02 20 <br /> 24 <br /> tN coUlyn, <br /> 7Ha� <br /> ACCEPTED BY:16v'q' "t �� , EMPLOYEE#: DATE: �� I(CZ I -Z`T <br /> ASSIGNED TO: C�aucllct EMPLOYEE#: DATE: (DI f 0 Z I Z 4 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: $���L �� Amount Paid Payment Date 2 'L4 <br /> Payment Type Invoice# G#teelr l L{ ��'� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />