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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 /> e _ I n CHECK if BILLING ADDRESS❑ <br /> an <br /> FACILITY NAME <br /> SITE ADDRESS S }(� �'a I T(<<i—_c!;'l <br /> Street Number Direction �Ck 1 ` Ci f I ) Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> LStreet Number Street Name <br /> CITY STATE ZIP <br /> stocklon C <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( )za g r y5-63 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> 1 C <br /> BUSINESS NAME PHONE# EXT. <br /> 20 9 l 5 � <br /> HOME Or MAILING ADDRESSI �` FAX# <br /> V a e(ca ( ) <br /> CITYC STATE n IP r 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 FEDERAL laws. <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 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 I�,Fy� to me or my <br /> representative. PAY W�Cry' <br /> TYPE OF SERVICE REQUESTED: R <br /> EGENED <br /> COMMENTS: APR Q 2024 <br /> SAN JOAQUIN COUNTY <br /> fiEALVIRONMENTAL <br /> TH DEPARTMENT <br /> I <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: G� <br /> Date Service Completed (if already completed): SERVICE CODE: P I ✓Wb <br /> Fee Amount: I�� Amount Paid 2 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 �� ✓51�3. <br />