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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS 12000 <br /> FACILITY NAME � 4 C40 , h, <br /> SITE ADDRESS 6/ ^� � G live <br /> street Number Direction street Name Ity Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> (510 ) f? 3 �" To T <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 r L PHONE # EXT. <br /> 416 I 'S <br /> - 9 <br /> HOME Or MAILING ADDRESS / �/ r e �t C� CT � � FAx # ) <br /> CITY STATEC ZIP 7A92AS <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 <br /> or activity 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 FEPEYAL laws . <br /> APPLICANT ' S SIGNATURE : DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPrfZATOR / MANAGER ❑ OTHER AUTHORIZED AGENT c <br /> If APDL/CANT 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 <br /> above site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative . <br /> TYPE OF SERVICE REQUESTED : GAJJ &�� � <br /> COMMENTS : It 'WICPitt <br /> FCZIVEA <br /> 1AY <br /> 8AIVjo 2 2022 <br /> '4 TVIRONMF OUN�, <br /> ACCEPTED BY: EMPLOYEE # : (f C DATE : . j y TME'NT <br /> ASSIGNED TO : �u . EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : P I E : <br /> Fee Amount : Amount Paid p ✓oLf Payment Date ( 22 <br /> Payment Type Invoice # eck Z4 t �5 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />