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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST K o5CI01 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRmm��8S3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> Lfl y 4 <br /> FACIyTY NAME <br /> l / <br /> SITE Street <br /> 5' , //C / <br /> 12 LI O Street Number Direction V6treet Namle�(� it � I Code? <br /> 0 E r(NAILING ADDRESS (If Different from Site Address) I' /m � <br /> Street Number VV V al -streetName <br /> CITY S ATE ZIP <br /> q52 2.01 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> X1 <br /> 5 JqoIB <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> J` I /e-h CHECK If BILLING ADDRESS <br /> B NESaS N E (/�Jy PH # G ^� EXT. <br /> S (6 � <br /> HOME or n�AILING ADDRES FAX# <br /> �6 0 S Y- ( ) <br /> CITY S TE 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;I <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. <br /> TYPE OF SERVICE REQUESTED: `v'l l CUY�SUIk TLI�C n �C�LJ A <br /> COMMENTS: IVF <br /> Sc�I�tu� C:lcurc� Cc�Luti, j A* �, D <br /> 9 <br /> h WRQo 'VCOo24 <br /> F'q[TjiD pgRNT,q� TY <br /> ACCEPTED BY:by'1Cknne NN EMPLOYEE#: DATE:'?��iC� `L ' <br /> ASSIGNED TO: L'1 ( EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (Z( I P/E:' (V3 <br /> Fee Amount: U.2 Q,(L Amount Pai ��D� Payment Date <br /> Payment TypeInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />