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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> _ Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> -TLr NAME <br /> ITE ADDRESS �` f / TL� <br /> / 1 Street Number D rection / - Street Nameit1 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Addre s) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Zo CT <br /> PHONE#1 / EXT. APN# LAND USE APPLICATION# <br /> (�(0 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L�Lt CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: x-.67 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tule <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 pro _me or my <br /> representative. I Re <br /> TYPE OF SERVICE REQUESTED: ,, LIti oVF <br /> COMMENTS: <br /> -SAI, <br /> ENI,7f? N COU <br /> HS,�TMD'epMR��Nrl' <br /> ACCEPTED BY: �LLI' EMPLOYEE#: DATE: { <br /> 2 J ZL Zq <br /> ASSIGNED TO: t`1' EMPLOYEE#: DATE: `2I Z N2L 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �D 3 <br /> Fee Amount: 1Uxc I <br /> Amount Paid 1 a�- Payment Date 2W 2 <br /> l <br /> Payment Type LI Invoice# �� 83 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />