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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA0(r)oaj,58 S'ZW BG8` LA <br /> OWNER/OPERATOR <br /> FV-) Q -ps)\ ' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME S'o <br /> SITE ADDRESS v <br /> Street Number Direction J Street Name Ci i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S �;�V !\� <br /> Street Number J Street Name <br /> CITY C^\ D ` 1 t ` STATE ZIP gc� <br /> P0 #1 ExT• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO � <br /> `„,^ C CHECK if BILLING ADDRESS <br /> BUSINESS NAME[^ v` 1` v \ - �<' (i � ()P '_ ' <br /> 't \ ( 1 <br /> HOME or MAILINGADDRESS ( <br /> FAX# <br /> CITY STATE � ZIP vn ` EMAIL) / <br /> v V V L(/111' <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 perfo m d will be done in accordan with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE a ED L laws. JJ�� <br /> APPLICANT'S SIGNATURE: DATE: �J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG ❑ 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. PrATMENT <br /> TYPE OF SERVICE REQUESTED: G lhGn Cj t` OF (fit a1zY:�4U RECEIVED7 <br /> COMMENTS: <br /> JUN 16 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 8� ��op EMPLOYEE#: (p j DATE:Q>(J/r(o 2Q)23 <br /> ASSIGNED TO: V-(Aa EMPLOYEE#:(p Z J-1 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE:0(11 P I E: (oQj 2 <br /> Fee Amount:$<<j�,Q� Amount Paid S�o Payment Date l L ?] <br /> Payment Type V Invoice# CpeIk# 3 22 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />