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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> .,.,A <br /> OWNER/OPERATOR <br /> C 0 , I`A C f„ +-IYj i^A L-L <br /> FACILITY NAME CHECK If BILLING ADDRESS❑ <br /> (�( 11'1 <br /> C© .S LA CO NI. -PA LL <br /> SITE ADDRESS <br /> ` 1 Street Number Direction / T A Street Nam4 1 r `J'D [Nib <br /> �Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sa Street Number Street Name <br /> CITY C STATE ZIP 9 S-3 -1 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# Y, <br /> 3 SS 3 tv i A <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> d C '1��v t o J JVD <br /> BUSINESS NAME PHONE# EXT. <br /> (o ' U _ CoINIr0 0, ) -- 3 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY n �, ^ STATE ZIP (� ,1` 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 ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TA an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r 7-0*L <br /> PROPERTY/BUSINESS OWNER E /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BI 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. cc <br /> TYPE OF SERVICE REQUESTED: v` Q t I `l - , <br /> COMMENTS: PD <br /> N <br /> "R 08 20Zy <br /> H� DFpM 1 n' <br /> q/PTMFN <br /> ACCEPTED BY: V Y" ,1 v� A EMPLOYEE#: DATE: <br /> ASSIGNED TO: C-, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (17)Cc, PIE: <br /> Fee Amount: (o'2- TAmount Pai Payment Date <br /> Payment Type Invoice# Check# ` Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />