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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> St206) s & 6 ,5 �+ <br /> OWNER / OPERATOR <br /> er V(3 ;`\ CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> SITE ADDRESS U - k-Idc to <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> 1 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE]# 'I ExT . APN # LAND USE APPLICATION # <br /> v L <br /> PHONEY#2 ExT . EMAIL BOS DISTRICT [LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ! VN1C t� � ` CHECK If BILLING ADDRESS ❑ <br /> BUSINESS NAME f v ' O j �S SSS PHONE # ^ EXT . <br /> VV I * ` i '; `l /�<) �l v Zl o Z <br /> HOME Or MAILIN ADDRESSAj P ' � Aic FAX # <br /> CITY r' TG ,\J <br /> STATE /A ZIP cC T <br /> 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 and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE : <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I 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 /> Pi <br /> TYPE OF SERVICE REQUESTED : 1\-lCC � �1 \ � c: CSi CRj ',A S kw4JV-F ►� REC+ <br /> COMMENTS : <br /> JUN Z U 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : 5rIC�r� r� ,� EMPLOYEE # : Cj �? � S DATE : � (� � 'LCCIZ(bZ3 <br /> ASSIGNED TO : EMPLOYEE # N L.58 C DATE : Q> (, 2, 01 Z � 2 <br /> Date Service Completed ( if already completed ) . SERVICES CODE , PIE : <br /> Fee Amount : <br /> C5 co cal Paid l5� Payment Date 66 <br /> Payment Type U c,7) Invoice # k # l O j sq Received By: <br /> EHD 4 & 02 -025 SR FORM ( Golden Rod ) <br /> 03/22 /23 <br />