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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 1/5-3 5 .06W 5 T/\?r fI VE• -5 rock:.rOIJ <br /> Street Number Direction Street Name city Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) E <br /> 5 Street Number F Street Name �v <br /> CITY STATE ZIP <br /> MAR <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# V JOA <br /> QljN1V 91 F0 1iN COVN <br /> PHONE#2 ExT. EMAIL BOS DIST ICT LOCA I MEN <br /> ( ) 7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 71O CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE <br /> PHONE# EXT. <br /> eqE4t4gVa6 z-14.5" <br /> HOME or MAILING ADDRESS 1 FAX# <br /> a ( ) <br /> CITY STATE ZIP EMAI <br /> LL C' .ne <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 a ication and hat the work to be performed will be done in accordance with all SAN JOAQUIN` <br /> COUNTY Ordinance Codes, StandardCTEnd F L laws. <br /> APPLICANT'S SIGNATURE: lelwy DATE: 3 / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑/ <br /> If APPLICANT is not the BILLING PARTY, proof Of uthorization 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: <br /> COMMENTS: /- e <br /> 'h <br /> A <br /> � ld. a�[o(e"k*-, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L� EMPLOYEE#: DATE: ! 1 <br /> Date Service Completed (i ready completed): SERVICE CODE: 23 PIE: O� <br /> Fee Amount: '72•Z Amount Paid � a U�) Payment Date 3 I <br /> Payment Type (7V Invoice# Check# 07� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />