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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ,.NW V 8$ C152-4p <br /> 14 035 Street Number Direction Street Name Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) yN� <br /> DCAd!�JStreet Number Street Name C1 S <br /> CITY STATE ZIP <br /> DOST o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (CpCcl) 3Li5 — --79 <br /> PHONE#Z ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 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, ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3 Ia +1 L q <br /> PROPERTY/BUSINESS OWNEkd OPE OR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ©`,(�N <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign IS required 7'itle <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 Illy <br /> representative. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: #VASCF/VF <br /> AW 222 O <br /> �o 0 <br /> yVgQU/N <br /> 847-, <br /> FlTN jipMF4��Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �/r i PIE: ) <br /> t � <br /> Fee Amount: 2 — Amount Pai `coot O� Payment Date 2 v <br /> Payment Type Invoice Check# /01z 1 <br /> Receive By:OD <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 -Piz 6 �'z 0 10 I,1 <br />