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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> f r�0&�t9� 5Ro 4 � ® a � <br /> OVVAER / OPERATOR <br /> I ��1 ��,� CHECK If BILLING ADDRESS <br /> 13 <br /> FACILITY NAME l 1, ` <br /> Z) � - <br /> SITE ADDRES.$ <br /> 3 <br /> Street Number Dlrection d <br /> rest Name Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #Z ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t ' �r <br /> 1 � � � f ��• CHECK if BILLING ADDRESS <br /> BUSINESS NAME ,- PHONE ExT• <br /> r 1C X11 iC7 ( Lj&), ZA 3 -- .; 0 c <br /> HOME or MAILING ADDRESSMMMMM nn . }y-�t� I, FAx # <br /> 1 1 ' Vl�v/ ( ) <br /> CITY 5a` ,. STATE / f /A ZIP qg1 ` r7 <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 <br /> activity 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 I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ C! Y C Y "' <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative . l p <br /> TYPE OF SERVICE REQUESTED : REM ? <br /> COMMENTS: W LJ <br /> JUN 2 2024 <br /> SA NJC)AVIRp UiN COUNT <br /> HEALTH pE AR TAL <br /> ENT <br /> ACCEPTED BY :, (� JJ J � EMPLOYEE #: DATE : 3 <br /> ASSIGNED TO: � � EMPLOYEE #: DATE:4 .3Z <br /> Date Service Completed (if already completed) : SERVICE CODE: �� ' �i PI E: z3aO <br /> Fee Amount: C _ Amount Paid L f gF( Payment Date (r 2 <br /> Payment Type C� Invoice # Check # �S�J Rec ved By : <br /> V ; sem- ' lel �8790�- <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />