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FACILITY ID # <br />Street Number <br />City State <br />apn#Land Use Application#Ext. <br />BOS District Location CodeEmailExt. <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Ext,Business Name <br />ZipState <br />Type of Service Requested: <br />Comments: <br />Employee#: <br />Employee#:Date: <br />Service Code: <br />Invoice # <br />EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />City Zip Code <br />SR FORM (Golden Rod) <br />M J>al 2°>2-3 <br />Accepted By: Q <br />Site Address <br />HOME or MAILING Address (If Different from Site Address) <br />Street Name <br />Zip <br />Payment Date <br />Phone #1 <br />( ) <br />Phone#2 <br />() <br />Check if Billing Address LJ <br />Check if Billing Address £] <br />_______________<-<>_______________________ <br />ASS.GNEDTO: <br />Date Service Completed (if already completed): <br />Phone# _ ,(qtg> &uho <br />( )__________________ <br />Email <br />Fee Amount: W" A ' <br />Payment Type <br />2 S ^3 <br />D>TE: <br />Y-- <br />Received By:^^^^,,z <br />Amount Paid <br />Check # <br />Type of Business or Property <br />Food <br />Owner I Operator <br />''ifi.TfiWW S/iVg/(________ <br />FA<:|UT¥NAME Pti/VOMI OWTio/f <br />Street Number Direction'Street Name <br />fWJ7?g-E J'Q/VCT>O/V <br />Home or Mailing ADDRESS <br />Pi PGSTo/Vg______________ <br />C|TY _________rflSTATE ZIP 463^0 <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 />APPLICANT’S SIGNATURE: ^^Date: <br />Property I Business OwnerO '- " Operator I Manager Other Authorized Agent <br />If AppLiCA&bis-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.