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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'E"JZW 3-�(b31 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS //15-3 /� n VOP-? C% G �'� ��6ity <br /> L1 <br /> Street Number Dir ction C Street Name ZiCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> /-S;7-7- X30 <br /> PHONE#2 ExT. EMAIL BOS DISTRACT LOCATI�C DE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> � :6 m .,LCr V�-rre i V CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH N 1� _ EM' <br /> ( O" <br /> HOME Or MAILING ADDRESS (I �� e O/�—r�s FAX# <br /> �11(,Aj A <br /> CITY x c �`��1� STATE n p ZIP Q -;2 /— EMAIL <br /> BILLING vACKNOWLEDGEMENT: 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 /> x APPLICANT'S SIGNATURE: DATE: 1 —� <br /> PROPERTY I 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 provide to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: SN <br /> COMMENTS: nu � A,I � / <br /> ✓ lo- Q/jj <br /> SU � O� ?Z <br /> 3 <br /> EHVAQ/-7UNH <br /> uN <br /> Ep,�14'e <br /> ACCEPTED BY: �' EMPLOYEE#: DATE:'11 <br /> ASSIGNED TO: 117Q EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZ-3 P I E:;2-&t?Z <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 <br />