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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# S�ERV�REQUEST T e of Business or Property 2� `7b5 <br /> r1 uy, - 01 <br /> OWNER I OPERAT fa / CHECK If BILLING ADDRESSF� <br /> FACILITY NAME I I /l' <br /> u <br /> SIT DDRESS / /3G\a C hY' 11 �U CI Zi Code <br /> Street Number Olraclion � Street Name <br /> HOME or MAILING ADDRESS (It Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> ll�� Ear. APN# LAND USE APPLICATION# <br /> PR'�`� ' 1 <br /> Fxr BOS DISTRICT LOCATION CODE <br /> CONT CTOR/ S�1ERVICE REQUESTOR <br /> REQUESTOR <br /> y`� II l/1 IA/� 1 Ii��L.1/�P�/ CHECKIf BILIJNG ADCRE55® <br /> ll Il (�Tu ,u� PN 11 <br /> IUI LvI \(�tY� 111L�(i <br /> BUSINESS NAME I/� I Y 1 \ L'() <br /> [J J FAx# <br /> HOME Or MAILI UG ADDRES ( 1 <br /> CITY �J � <br /> BILLING AC OWLEDGEENT: I, the undersigned property or business owner, operator or authorized agent s same, <br /> M <br /> acknowledge that all site and/or project SpCCIIIC 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 YPI15111on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St ndards S nd F D RAL law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> JfAPPUCANTis not the BtLL1,VGPARry proof of authorization to sign is required TCIte <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: <br /> COMMENTS: RE/��1V`ND <br /> SEP 12 2022 <br /> HA N RON/N CDU/V <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DAT .PARTMENT <br /> ASSIGNED TD: , es 11 11, EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 1 <br /> Fee Amount: Amount Paid I �1 n i Payment Date 2 Z—T <br /> Payment Type '6 Invoice# J t� �� 3� Received By /J <br /> EHD SED 1111 ` -A q 1 "7 2 ` r1 SR FORM(Golden Rod <br /> REVISED 11/17@003 1 v T J J ) <br />