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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C 'nVP--ot <br /> OWNER/OPERATOR <br /> `l� CHECK if BILLING ADDRESS <br /> � SO1 <br /> FACILITY NAME Ac f p ,\ /� ^ , <br /> SITE ADDRESS 3 6t)O G� 1 ` I/ /� e-a-ry) Eso <br /> �G� 0l. ompo `".I1J d D-0Street Number Direction / , r 1treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3o U r u( V Street Number Street Name <br /> CITY STATE ZIP <br /> S (110 q 5 1`,°U <br /> PHONE#t Ems• APN# LAND USE APPLICATION# <br /> PHONE#Z _ Ex-r. EMAIL• n' BOS DISTRICT LOCATION CODE <br /> f�n C I'Y1i,(5�t l tr� &I l00'CbyV` <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <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, Stand7akJ <br /> STATE and F RAL laws. <br /> APPLICANT'S SIGNATURE: AwDATE: ki It 20 2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OT ER AUTHORIZED AGENT ElIf 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. /4W <br /> TYPE OF SERVICE REQUESTED: � ecel / <br /> COMMENTS: <br /> AN 1 1 1024 <br /> $EN VIROpV N COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �fv d s EMPLOYEE#: DATE: —I I `7 <br /> ASSIGNED TO: �!�Jv-o 2-&f'- EMPLOYEE#: DATE: 1 -I' <br /> Date Service Completed (if already completed): SERVICE CODE: `' P/E: <br /> Fee Amount: + Amount Paid Payment Date i I <br /> Z <br /> Payment Type C� Invoice# Check# Z Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23TR D 1 �0 0 2 <br />