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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r - <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 0 -\ Q (-e <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S 2 r 1�—�. �h y <br /> f1 - ���Y <br /> St et _�et Number Street Name <br /> CITY SPATE P <br /> PHONE#t _ ExT. APN# LAND USE APPLICATION# <br /> o(_;F) - V-1 92-1 <br /> PHONEW2 ExT. EMAIL BOS DISTRICTLOCATION CODE <br /> ( ) 1-01 C{•SCJ c 1.�to.h c�n CCl cuo.maij(i� 7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> "o, reel- CHECK if BILLING ADDRESS❑ <br /> C(�ou INS ►- <br /> BUSINESS /I � ry _ (_-S1� PHONE# I : \ � 1 � ExT. <br /> HOME or MAILING ADDRESS V FAx# <br /> CITY STATE �' ^� ZIP C t �� �- 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. I <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUINI <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE; 1 Uq�y I , 207V <br /> PROPERTY I 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 IS provldd to me or my <br /> representative. Nq <br /> TYPE OF SERVICE REQUESTED: d G pr <br /> �- <br /> COMMENTS: IA <br /> N 9 <br /> � y <br /> ACCEPTED BY: �\ �p EMPLOYEE#: DATE: \ \� <br /> ASSIGNED TO: G—k EMPLOYEE#: DATE: \ yz <br /> Date Service Completed (if already competed): SERVICE CODE: C P I E: <br /> Fee Amount: vs-/2- <br /> /) Amount Paid l(-Qa — Payment Date I 1q 2-4 <br /> Payment Type C1 � Invoice# CM `�5`(��b--0 Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 f1k0SqgHq1 5 <br />