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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F�mm23(I C-1 t SCZCp,-9 830 <br /> �/Ouf OWN�R/OPERATOR <br /> hr/�M Q <br /> 1 � CHECK If BILLING ADDRESS <br /> "165, <br /> ` FACILITY N <br /> T r l� <br /> al c-'r�^2 <br /> SITE ADDRESS t I }' <br /> cc"-A"SSF'1 ( �(�Street Number Direction V t i heet Name i LSde <br /> J HOME or MAILING ADDRESS (If Different from Site Address) <br /> �c'V4/ Street Number Street Name <br /> ham.,L CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT -[-LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> v'e- CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( ) <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 a DERA ws. l <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 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 dr to me or my <br /> representative. Ahp <br /> TYPE OF SERVICE REQUESTED: IV <br /> COMMENTS: ,1 <br /> svj 8 <br /> y ?4?y <br /> H EROHI N COON <br /> "46N r <br /> ACCEPTED BY: �1,� L I( �C � EMPLOYEE#: DATE: �1 i g�-zq <br /> ASSIGNED TO: LJ <br /> 1 ck -y a Ker <br /> EMPLOYEE#: DATE: -j`'b 1ZLI <br /> Date Service Completed (if already Completed): SERVICE CODE: (Q(p j P/E: 0 J <br /> Fee Amount: 1 a Amount Paid `Ua — Payment Date 3 <br /> w 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />