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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rrA)ho � hOe 5ZQ0 87? 3(o <br /> OWNER'/OPERATOR I <br /> tr CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> e- <br /> SITE ADDRESS }�/1�/► `y�,,l/n � �,,", `, <br /> 210 street Number DirectionU 1"N Strdet Name —1 v�City�JZ(i'(JCode <br /> HOME or MAI ING ADDRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> CAA <br /> PHONE#1 ExT• APN# LAND WE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> �Twl Z <br /> BUSINESS NAME 1 I \��C�j )CA t -- PHONE# C� 05 J EXT. <br /> HOME or MAILING ADDRESS \, J V ` FAX# / <br /> Sqo� c`S1�fl� r, c <br /> CITY STATE ZIP C EMAIL i I / <br /> r C� x{5 2 0 - 1 �i nGt 1�'S4 6cn 11*b 1 2 L/ {�f - <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. �J <br /> APPLICANT'S SIGNATURE � DATE: I n-14- 1 <br /> PROPERTY/BUSINESS OWNER43 OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i 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: oc(l A0 Co()S�Atol br-) P <br /> COMMENTS: <br /> REcE�V�nT � <br /> sA,vgR ,9 242y <br /> �EACt�RONti1F OUN <br /> )Y <br /> ACCEPTED BY: 1 I EMPLOYEE#: !�� ( DATE: T <br /> ASSIGNED TO: s'I n , EMPLOYEE#: LJ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CI _ I P/(E: L-I (�3 <br /> Fee Amount: I Z Amount Pai / ,) b D Payment Date 3 <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />