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0 5 Oto X15 <br /> SAN•JOA(�UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A A/ �, �� .-�- SRm®8-7sa(o <br /> OWNER/OPERAT--^ • r <br /> - �� (:� 1 ■ � CHECK if BILLING ADDRESS <br /> FACILITY NAME / 4 <br /> SITE ADDRESS �• �'} <br /> C-6 Street Number Direction V�Gr�Str t Nc� ameQ� C <br /> HOME or MAILING ADDRESS (If Differe"t from ite Address) s -a&0%1 -rr � <br /> {i+1v aV IV I t Number a Street Name <br /> CITY • C . STATE <br /> V 1/-e�'Ir<a� <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REQUESTOR <br /> CHECK if BIL � �' <br /> As <br /> 81cc --W1 <br /> BUSINESS NAME PHONE# <br /> HOME or MAILING ADDRESS FAx# <br /> l 13 20 <br /> CITY STATE ZIP EMAILH FIVVjR p/N COQ <br /> I, the undersigned property or business owner, operator or authorized ;4ame, <br /> acknowledge that all Site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector aCZlvity <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 and FEDERAL laws. <br /> APPUCMrS SMATURE: ,W-? 4z�o DATE: <br /> PROPERTY/BUSINESS OWNI RR OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ O <br /> if APPLICAN IS not the BILLING PARTY proof of authorization to sign is required Tide ^� <br /> AUTtfl)RJEATIGN To RELEASE W42ORkIATION 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: A <br /> COMMENTS: <br /> A <br /> ACCEPTED BY: I EMPLOYEE#: DATE: / 1 Z 3 <br /> ASSIGNED TO: // r EMPLOYEE#: DATE:1 <br /> Date Service Completed (if already completed): SERVICE CODE: Ob\ P/E. l Lot <br /> Fee Amount: Amount Pai /6 2.00 Payment Date <br /> Payment Type l � Invoice# Check# i OI Z�+— Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> 03/22/23 <br />