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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SX-)v/a Dvcr--"irl <br /> ► (-t..;i C HS h or J <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> ^J r\ <br /> FACILITY NAME <br /> SITE ADDRESS LI-A-1 #/A) �Q (J <br /> c <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) H aL MG��L g W/1)\/ <br /> 10 C �,s /�� Street Number Street Name / <br /> CITY STATE ZIP <br /> " Ao cep (lS757 <br /> PHONE#1 E)rT• APN# LAND USE APPLICATION# <br /> 6-k) 1 45/08 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BELLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> 57 0A-57- 00 ( ) <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 and FEDERAL law <br /> APPLICANT'S SIGNATURE: -171 DATE: — ,2o,23) <br /> PROPERTY/BUSINESS OWNER,❑ OPERATOR/MANAGER ❑ ATHER 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 proe or my <br /> representative. /' , <br /> TYPE OF SERVICE REQUESTED: IVF <br /> COMMENTS: , 4 <br /> 2423 <br /> H FNVjR�ViN COV <br /> EACTH t)pAR L <br /> ACCEPTED BY: tr c✓ EMPLOYEE#: DATE:G —23 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> - <br /> Date Service Completed (if already completed): SERVICE CODE: ! _ PIE: &0 Z <br /> Fee Amount: 162— <br /> Amount Paid I LQ 2 Payment Date C3 1412-3 <br /> Payment Type v Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />