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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAMBOS4 SRmm B-+(0Sp <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITEADDRESS/y/9 N ��I r— <br /> "Street Number Direction / C �C S(raet Name ` GC O c Zi 4o?d e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> //U 5 Z—O (ic <<L Street Number Street Name <br /> CITY _ STATE ZIP <br /> I O L r"G /1-1 A <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (Z` YE <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ('-1-V�) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR r—, <br /> (-K3Q S (� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME r-\�� , (� �� PHONE EXT. <br /> HOME or MAILING ADDRES r- FAX# <br /> W f N S 1--o w t-`I �( S �.� O ( ) <br /> CITY Qv C' (C ^O N SC TA ZIP 21 U 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: '4-z-- DATE: L) ( Z 4 2 <br /> PROPERTY/BUSINESS OWNER[3 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 iSpf Vied to me or myl <br /> representative. /.A' Afemr <br /> TYPE OF SERVICE REQUESTED: C,`nQn Q Q�l�V��C Sh l P EIVED <br /> COMMENTS: IV 2 4 <br /> 2024 <br /> 1j' uti <br /> ry <br /> D,e <br /> ACCEPTED BY: P)Y 1UYlY1 `\ EMPLOYEE#: DATE:ml �2'A I 7-1A <br /> ASSIGNED TO: L C) Cl 8 EMPLOYEE#: DATE:Q)112#{ 12q <br /> Date Service Completed (if already completed): SERVICE CODE: (LG k P I E: `602 <br /> Fee Amount: Amount Paid l Payment Date t12-4` 2-LF <br /> Payment Type Invoice# ��J O���3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 FV 0 5 2VIh 1 <br />