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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 /> du C L CHECK if BILLING ADDRESS <br /> . ., <br /> FACILITY NAME <br /> ATE ADDRESS n ^ Nu i l C a Zip j <br /> Id IIdt 'Street Number Direction Street Name CTt I Zi Code <br /> HOME Qr'MAILWG DRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY C�o d fi STATE ZIP <br /> PHOuNE,1 , Z `l� fl vZ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) 4/r0I'd 12M ILS 8 ,/• (Ofd I <br /> i , <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> Sdm e , 60�C� <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C C17 oqj DATE: OT/Z11202 <br /> i <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: kC'_*fU Vl <br /> COMMENTS: E1VED <br /> LIAR 2 12024 <br /> � 0AQUIlV COV <br /> HST H D,,pARTTA TM <br /> ACCEPTED BY: ���l�Al Y1R `,� EMPLOYEE#: DATE:�'3` I 1 Z L4 <br /> ASSIGNED TO: u3dia (-�) EMPLOYEE#: DATE: 3I 21 2�{ <br /> Date Service Completed (if already completed): SERVICE CODE: CO&( PIE: t(oQ>73 <br /> Fee Amount: S110 Z .QC0 Amount Pai v��„ �j� Payment Date 3�� 2 <br /> Payment Type 7�l2 Invoice# Check# 17g Tg r Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> ?K bc� 2552 <br />