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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of;Buspinss or Property FACILITY ID# SERVICE REQUEST# <br /> eOWNERRATOR �y <br /> � �Cal) �q�y e�3 .�; /t � CHECK if BILLING ADDRESS <br /> FACILITY AME � G�1 1 e V <br /> SITE ADDRESS <br /> 1 Street Number Direction " / , / V <br /> Street Name Ci Zi Code <br /> HOME Or I�IIAII,ING ADDRESS (If Different from Site Address) //♦,J / � Q "� /) .vim, <br /> (�/ 4 Street Number v v I EJ Street Name /_/ <br /> CITY r— STATE ZIP <br /> C <br /> PHONE#"I 1 Exr. APN# LAND USE APPLICATION# <br /> goo <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> 05 6b 7 <br /> Z--0 ,-4p 1 q a r CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTDR I / <br /> / —� CHECK If BILLING ADDRESS <br /> BUSINESS' AME LS PHONE# ExT. <br /> C <br /> HOME or MAILING ADD SS 7 FAX# <br /> z �� w e� v �� ( ) <br /> CITY72-xnL STATE ZIP p- EMAIL <br /> cp�Yl <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 ENVIRONMEN HEA)11H DEPARTMENT hourly charges associated with this project or activity <br /> will be billed to me or my business as identified on this 1/0,m. <br /> also certify that I have prepared this application and at t e wo to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDE AL I S. <br /> APPLICANT'S SIGNATURE: �%IDATE: t'y f � • ,���� <br /> PROPERTY/BUSINESS OWNERO)C OPERATOR/MAN' R ❑ OTHER AUTHORIZED AGENTS 71QQy�, <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 I cated 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: <br /> Ivie <br /> COMMENTS: 0 <br /> 72023 <br /> sA,,, <br /> EN F?OU1 CO Ty <br /> HEALTHDEp NrAL <br /> A TMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ! EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: . PIE: ( <br /> Fee Amount: ` Amount Paid Payment Date )0 1 - <br /> Payment Type Vl7 Invoice# C eck# ?) 3:E Received By: �i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />