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FACILITY ID # <br />Facility NAME <br />Direction <br />City State <br />APN#Ext. <br />Email BOS District Location CodeExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Business Name Ext. <br />Home or Mailing ADDRESS <br />City State Zip <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Employee#:Accepted By: <br />Employee#:Assigned to: <br />Fee Amount: <br />Payment Type Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />Check if Billing AddressI^J---------------- <br />ca cry? 3 7 <br />City <br />CovVM-yS\V2_ <br />Street Name_____ <br />/T33 <br />Street Number <br />Date Service Completed (it already completed): <br />Check if Billing AddressD <br />Phone #1 <br />Phone #2 , <br />(Xp?) <br />Phone # <br />J___L <br />Fax# <br />( <br />Amount Paid <br />Check # i <br />Type of Business or Property <br />_______Foe>& 7gAVL-£^5 <br />Owner / Operator . <br />Date: <br />Date: ( -Z.'j _ <br />P'E: | 10 I <br />Zip Code <br />L_ <br />Street Name____________________ <br />Zip <br />9 03'7 <br />Land Use Application # <br />J)E5\ H^T <br />Site Address <br />12- 32 CCVf1' I ''' ' Street Number <br />Home or MAILING Address (If Different from Site Address) <br />Service Code: <br />- Payment Date <br />nStblS TfV' Received By:" <br />j________ _____________________■> <br />Email Mz/z s <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 Federal laws. <br />____________ 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 />___^C^IVED <br />s JAN^20^ <br />^§57