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FACILITY ID #K <br />Facility Name <br />Dlroction <br />Street Numbor <br />City State <br />apn#Ext.Land Use Application # <br />EmailExt.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext. <br />City Zip <br />Comments: <br />MAY 0 2 2024 <br />0^13Employee#:Accepted By: <br />Employee#:Assigned to: <br />Service Code: <br />Amount PaidFee Amount: <br />Invoice #Payment Type <br />^(01 <br />Business Name <br />EHD 48-02-025 <br />03/22/23 <br />PAYMENT <br />RECEIVED <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />Zip Code <br />Date Service Completed (if already completed): <br />$ <br />77^ X <br />SR FORM (Golden Rod) <br />Phone # <br />( 2^1) ^oo- <br />Fax# <br />J__ <br />Email <br />Street Name <br />Zip <br />Type of Service Requested: <br />Site Address <br />_______________Street Number <br />Home or Mailing Address (if Different from site Address) <br />Phone #1 <br />(^) quo oi q i_| <br />Phone #2 <br />( ) <br />Check if Billing Address <br />2 <br />___________City <br />/z ; i------ lg| X'MhQ? / <br />/<^M-—• Payment D^te </ <br /># / 8 O Received By <br />7 7 ■ <br />C > q a e <br />Home or Mailing Address <br />Soo G k\)-e Vc C___________ <br />LPVv__________________ST.A Z'PqSAVO <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 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^RAL^aws. <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 is provided to me or my <br />representative. <br />SAN JOAQUIN COUNTY <br />ENVIR 3NMSNTAL <br />HEALTH DEPARTMENT <br />Date: <br />Check if Billing Address EJ <br />/\\)e g <br />Street Name____________ <br />Type of Business or Property <br />Owner/Operator <br />L.v<^dnes.