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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businl,e(s/ ty FACILITY ID#s or ProperN SERVICE REQUEST# <br /> S <br /> OWNER/OPE TOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Q t'��►'lQf a l�lo YV� �, <br /> SITE ADDRESS <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING Mv <br /> ESS (I Different from`Site Address) <br /> UC^ Street Number Street Name <br /> CITY STATE ZIP <br /> V- .v Cp✓l . C N\ p <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20 q3a--Q <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> ( <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, Stand rds, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE [/1 l , ✓ DATE <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 assessment i formation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provlA�Nl]fw,Qr my <br /> representative. / Ni' <br /> TYPE OF SERVICE REQUESTED: FD <br /> COMMENTS: ^ ^ 6 2024 <br /> ENVIRO V COVN <br /> HATH pEPAReN7Y <br /> ACCEPTED BY: EMPLOYEE#: /t_h�v DATE: 2" <br /> ASSIGNED TO: EMPLOYEE#: lffJJ DATE: Z <br /> Date Service Com eted (if already completed): SERVICE CODE: P 1.: f 0- <br /> Fee Amount: Amount Pai 2,d0 Payment Date <br /> Payment Type Invoice# Check# 17 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />