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FACILITY ID # <br />Facility Name <br />Site Address <br />Street Number <br />City State <br />APN #Ext.Land Use Application # <br />Ext.BOS District Location Code <br />Requestor <br />Ext. <br />City <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />NOV 1 3 2023 <br />Employee #:Date: <br />Employee#:Date: <br />Service Code: <br />Amount Paid <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />PAYMENT <br />REGBVEB <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Lod' <br />_________City Zip CodeDirectionStreet Name__________ <br />Date: ll I >5^5 <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 />MDH <br />Street Number <br />Home or Mailing Address (if Different from site Address) <br />Street Name <br />Zip <br />LO(A|_____________________^tate w ^ip <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 />5 o^3 <br />Payment Date <br />SERVICE REQUEST# <br />Check if Billing Address CJ <br />Check if Billing AddressD <br />Phone#1 <br />(LW 1^3 00 b6! <br />Phone #2(2,W) Wiz <br />Accepted By: <br />Assigned to: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Type of Business or Property <br />'Tnr-hil(9i -trailer <br />Owner/Operator <br />grwin Alber To Quir -Ver o z. <br />CVvv'/'os Vor-hikiJixy <br />luOF <br />Phone # , <br />(7,M) l/(z3 OO <br />Fax# <br />( )________________ <br />Email <br />\tf( ?>/ <br />: P,EZ KpOI <br />Received By: - <br />Home or Ma,uNG ADDRESS £ & <br />State r Zip <br />Date Service Completed (if already completed): <br />Fee Amount: | 4<g(p <br />Payment Type \j <br />Email , <br />________CONTRACTOR / SERVICE REQUESTOR <br />pi ■ 0\Ji rVero T-o l <br />Business Name