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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 AmCDQQXAcS 11S)Re)¢)pj-:,f�kg16 <br /> OWNER/OPERATOR <br /> j g—r � n �, CHECK If BILLING ADDRESS❑ <br /> s 70 <br /> FACILITY NAME <br /> SITE ADDRESS Q fi e- \ s j C n �, S��{0 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> G C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C CA <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> �' � -� L-i <br /> HOME or MAILING ADDRESS FAX# <br /> 1 r-\ <br /> CITY C VY <br /> CALM <br /> VC 1 STATE ZIP .i 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 FE ERAL laws. 1 <br /> APPLICANT'S SIGNATURE: ` DATE: V( 1 0 <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: CV-NCiil . f d OwneX sh tP EN <br /> COMMENTS: ED <br /> APR U4 2024 <br /> 0111 <br /> AL <br /> ACCEPTED BY: y-i C0 aR- t„l EMPLOYEE#: DATE: LA N V11A <br /> ASSIGNED TO: Fran6 SC-0 R , EMPLOYEE#: DATE:Lk1L11•Z, <br /> Date Service Completed (if already completed): SERVICE CODE: (�(�, P I E:I(CW- <br /> Fee Amount: .$ (ba, Amount Paid �� 2.�_ Payment Date Lfl 4 2 <br /> Payment Type Invoice# Check# D Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23PL 0 <br /> w <br />