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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P2 o5` so tS <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> I CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 11 Al s" <br /> tt Nu�ber Direct <br /> Street Name `� C `�� Zi Code / <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name e7 3)T <br /> CITY STATE ZIP <br /> PHONE#t _ ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME C'L (/ [ 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 pnd 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: <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 information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or my <br /> representative. p <br /> tea- <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �t�l <br /> SOW <br /> �OR�NiN <br /> CO O <br /> ry C�pM� <br /> ACCEPTED BY: EMPLOYEE#: r'7DATE: <br /> ASSIGNED TO: ` C EMPLOYEE#: � DATE: .— <br /> Date Service Completed (if already completed):-- SERVICE CODE: G�.�1/_ / P f E: <br /> Fee Amount: 2 Amount Pai l� .Z AD Payment Date 3 11� Z <br /> Payment Type (2,%6b — <br /> Invoice# Check# ecelled By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />