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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines or Property j FACILITY ID# SERVICE REQUEST# <br /> �f F S 12QxD��8 i� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS V/' �• t• �°v��!-3�. � /a S <br /> reeGm6er Direction (/ Street Name Zip Code <br /> HOME or MAILING ADDRESS (If Differe t from Site Address) <br /> V/.tr..t <br /> Number Street Name <br /> CITY STATEZIP <br /> e, S 2-0 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> Ove►) -S -3 U2 O <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> Z� ) <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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:I�\ DTE; <br /> PROPERTY/BUSINESS OWNER❑ 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 assessg information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it is or my. <br /> representative. R <br /> TYPE OF SERVICE REQUESTED: WCU <br /> COMMENTS: JOAQUI O?� <br /> i EI MRO N COVNTy <br /> MST H O p S NT <br /> ACCEPTED BY: EMPLOYEE#: '24 DATE: <br /> ASSIGNED TO: EMPLOYEE#: j L DATE: t / <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PI E: C <br /> Fee Amount: Amount Pai �(�2�,UD Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />