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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 L n <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> SITE <br /> /ADDRESS ber Nu 2 •y-��� -7„ j �rJ c� <br /> Y/ tmet Direction W ' 1J Sttr"eet-Name / /�C•�Cit) Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> street Number Street Name <br /> CITY-- STATS ZIP r <br /> J 5- 1 <br /> PHON #t EXT. APN# LAND USE APPLICATION# <br /> (Pcp yah -&-?,c\ <br /> PHONE#2 _ 1ryJ EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> i <br /> (. \ ) ( J _ Zc 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RES(T/OR <br /> 1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME /� f �S /�. , �� D �G PHONEJ�/ , n C, 1 Eur. <br /> HOME or MAILING(A'DIDRS FAx# G <br /> CITY <br /> STATE ZIP (e EMAI d <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sameQtM'� <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity (:Ij p" <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this appli . n nd t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar s and RAL laws. <br /> APPLICANT'S SIGN RE: DATE: ZI12— <br /> PROPERTY/ <br /> BUSINESS OWN R ERAT R/MANAGER)2--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. r L / MMENT <br /> TYPE OF SERVICE REQUESTED: n S G.X Tr �r U`� �OcTt� RECEIVED <br /> COMMENTS: APR 2 1 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C` � EMPLOYEE#: DATE: -2- �2-3 <br /> ASSIGNED TO: V `G� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: <br /> bm2 <br /> Fee Amount: (S(o CDCD Amount Paid /S Payment Date <br /> Payment Type Invoice# k# p CI 3� Received By: /J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />