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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r j\ch.(2)CID 3 spw?-n 17 <br /> OWNER/OPERATOR <br /> Y'U e C CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SI2 ADDRESS <br /> Street Number Direction Street Name cityZi Code <br /> HOME orMAILINGADDRESS (If Different from Site Address) <br /> 1 v".J 12 -I C^� Street Number Street Name <br /> CITY1J pt__ST TE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( 2ol Co 2 l ci 2�- <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTO CHECK if BILLING ADDRESS❑ <br /> Y-0 -0-;?—� <br /> BUSINESS NAME -- PHONE# EXT. <br /> L a Iq I s 20 Co Z q 'q2-7 <br /> HOME or MAILING ADDRESS FAx# <br /> CITY t n�n�C ri $T TE ZIS 3 .-,!? C-11 EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application a�d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F DERAL laws. t� <br /> APPLICANT'$SIGNATURE: 'L DATE: 2- <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER UTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule <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: MENT <br /> COMMENTS: RECEIVED <br /> MAR 13 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: bvtC111t1E EMPLOYEE#: DATE:'3)kV jA'2L{ <br /> ASSIGNED TO: C-)� I EMPLOYEE#: DATE:'3113�2� <br /> Date Service Completed (if already completed): SERVICE CODE:QJ�O P1 : (D 2- <br /> Fee <br /> Fee Amount: A i 1,-Z oar I <br /> Amount Paid 4a Payment Date 3 f d-c <br /> Payment Type lC)� Invoice# C c # Received By:H:4 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />