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P2. 0s �-lS X82 <br /> 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/ <br /> IFACILITY NAME <br /> SITE ADDRESSI U V �r^� (ck r C.�— S+V C ki 1 U, C� <br /> ` <br /> Z -L Street Number Direction 0 me Street NaCiti Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site ddress) <br /> 2 _ Street Number Street Name <br /> CITY �(^ <br /> STATE f !��ZIP <br /> ` V 1`�1 JY� fill <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <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 /> 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 all' EDERAL laws. <br /> APPLICANT'S SIGNATURE: �w ti DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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. <br /> TYPE OF SERVICE REQUESTED: Yljll <br /> COMMENTS: 01? <br /> AN'j4%1111 o�2.� <br /> ��rh pFp F/yTq'v rY <br /> ACCEPTED BY; EMPLOYEE#: VP 3 DATE: N Z <br /> ASSIGNED TO: Q� t N�i(� EMPLOYEE#: v[ J DATE: L02xYl <br /> 7 <br /> Date Service Completed (if already comple ed):-+� SERVICE CODE: I O <br /> Fee Amount: Amount Paid ��� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 y <br />