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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 o <br /> a, 1 1 U � C CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ^ �1 a)I <br /> SITE ADDRESS <br /> Street Number Direction "� v 1 Street N I v "fit Zi d)�� <br /> HOME or MAILING ADDRESS (If Different from Site Address) ' O n /� <br /> Stfeet Number \ yu <br /> Suet Name <br /> CITYl\ `\ (-�/� t^ STATE ZIP O <br /> PHONE#t �1,v� t ` ExT. APN# LAND USE APPLICATION# I <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 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 JOAOUINI <br /> COUNTY Ordinance Codes, Standards, ST TE and FEDERAL 18WS. <br /> APPLICANT'S SIGNATURE: _ DATE: �_ 1 ,5- a a 3 <br /> PROPERTY/BUSINESS OWNE PER /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT IS hot fhG 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 localad at the above site <br /> AMAIaddress, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessm o the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS SOOn as It IS available and at the Same time It IS r my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: MAR 15 <br /> 424 <br /> COMMENTS: JO <br /> MAQUIN <br /> �h"W NNfi�.ilt�Nry <br /> �+7LIYr/7 'PMrWNr <br /> Ghon wi nc Owl cfsh R _ <br /> ACCEPTED BY. EMPLOYEE#: � ) DATE: i 5 ZL/ <br /> ASSIGNED TO: 212-' <br /> EMPLOYEE#: lJ DATE: / <br /> Date Service Compl ted (if already completed): SERVICE CODE: P/E: r 2 <br /> Fee Amount: O Amount Paid Payment Date <br /> Payment Type I Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> P� 0 5(-1(Da2 <br />