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FACILITY ID # <br />Check if Billing Address <br />icaHons <br />(o-y Street Number <br />APN# <br />Location Code <br />I <br />Requestor <br />Ext.Business Name <br />Home or Mailing Address <br />ZipStateCity <br />l-i uzyAPPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Employee#:Date:Accepted By: <br />Employee #:Assigned to: <br />Service Code: <br />Amount PaidFee Amount: <br />Invoice #n <br />SR FORM (Golden Rod) <br />Date Service Completed (if already completed): <br />____________ <br />Payment Type <br />I also certify that I have prepared this <br />County Ordinance Codes, Standards, <br />EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />-------1 <br />SERVICE REQUEST# <br />Zip Code <br />L\J <br />Direction <br />Check # <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 />^plication and that the work to be performed will be done in accordance with all San Joaquin <br />■ate and Federal laws. . ____ ) <br />Check if Billing Address <br />--Email Z ~ [ BOS District <br />CONTRACTOR / SERVICE REQUESTOR <br />Street Number <br />REPRESS (If Different from Site Address) <br />Date: <br />Property/Business OwnerOperator / Manager O Other Authorized Agent [Jl <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 />representadve. ---------- ----------------------------------- <br />_________________Street Name_______________ <br />State Zip_r, _ __ <br />CV\________^20/ <br />Land Use Application # <br />Phone # <br />J__1 <br />Fax# <br />J__)_ <br />Email <br />Phone #1 ext. <br />rem 6o L sSiy <br />P^t qs4 -6W"' <br />g CA <br />Payment Date <br />Type of Business or Property <br />Owner/Operator <br />Facilw^Iame <br />Site Address <br />HoME-er Mailing <br />E O' <br />City <br />Date: \ f \\ <br />P/E: Vvs,?. <br />8/8 _ ~ <br />Received By: