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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �:A OTIT251 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FA ITY NAME <br /> t' r r Q(A- r <br /> SITE ADDRES //��) ✓ // / / Z <br /> '201Street Number Direction Air / Street Name ST aG ICI y Zip Code <br /> �S <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> L L_ / �1 <br /> (- a lC v G VlJ Cn— Street Number Street Name <br /> CITY,^ o�°\ ST-�ATE g 3(o <br /> V 1, ' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zcfl) 3o3 -3 3 33 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUES/TOR CHECK if BILLING ADDRESS❑ <br /> Cts`V'. c15S'�Y <br /> BUSINESS NAME PHONE# EXT. <br /> I r for �; 6303- 33 33 <br /> HOME or MAILING ADDR SS FAX# <br /> 7CO /V L( Vo r t w G <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 /> i <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I 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 t0 me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: �L`)Gh <br /> COMMENTS: <br /> 9 <br /> at�q�, 1 <br /> S�Jo <br /> FNEp <br /> V1R QUI/y COU <br /> H�CTy pgRWT,q��1' <br /> R <br /> ACCEPTED BY:-BY 1 C,Inv)-e EMPLOYEE#: DATE:07" A-2-CA 1'2 L4 <br /> ASSIGNED TO: CkC1 U CI C) EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:0(�-1 P I E: (O&Z <br /> Fee Amount:$I(02.(� Amount Paid / b� Payment Date 2`� Z <br /> Ll- <br /> Payment Type C7c� Invoice# Check# g�2-S-� Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> PR I�o��01 (5 s <br />