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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> l / f <br /> L" Gt f/ �G �� �� �e �1 � CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME 1 ) �nCCCC 11 1 C I <br /> Wtr lY cCt t iL v^ Cj y1i� <br /> / - uL_ cc A lock r . <br /> SITE ADDRESS �s Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address) /S- Awa of /G I,✓ cr if [ ( •e ( t <br /> P Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 ExT • APN # LAND USE APPLICATION # <br /> ( �2 r �) <br /> PHONE #2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> <lir ,(re , <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L I t 4 � � /� CHECK If BILLING ADDRESS <br /> BUSINESS NAME C I ` / I PHONE # EXT. <br /> r L ' C f f r � e rc� 201Tc 7 5e <br /> HOME or MAILING ADDRE S _ FAX # <br /> CITY r STATE C 14-- ZIP � j- L, 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 FED s . <br /> APPLICANT ' S SIGNATURE : DATEzl j z( Zc cJ <br /> : <br /> PROPERTY / BUSINESS OWNER ElOPERATOR / 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 assessmen ' on to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS pr�iI, y <br /> representative . ' ` C <br /> TYPE OF SERVICE REQUESTED : V S \ RQ ctl <br /> COMMENT P t SAM JO <br /> FMVIAQU/ly C 41 <br /> H�rHo pAROIJN7y <br /> ACCEPTED BY : � �� F� 1Un ;� EMPLOYEE # : DATE : <br /> ASSIGNED TO : ( , L� �i � tZ1 � 1 �C ' J\ Q11 t EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed ) : 1 SERVICE CODE : t ��� PIE : a � <br /> Fee Amount : LAI I(0 . Ob Amount Paid 14 00- - 4 Payment Date a I/pq a � <br /> Payment Type /I . Invoice # e k -� 2J Received By: <br /> Utz <br /> EHD 48 -02-025 SR FORM ( Golden Rod ) <br /> 03122/23 <br />