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SAN JOAQUIN COUNTY ENVIRONMENTAL (HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR / <br /> CHECK If BILLING ADDRESS ® <br /> 10'9lS , CCAIA IV 457 <br /> FACILITY NAME <br /> SITE ADDRESS GI � - c5 TO ek4 ,0 � 5 ,2 <br /> t�t Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> 0 , Street Number Street Name <br /> CITY STATE ZIP <br /> 5 do a <br /> PHONE # 1 Exr . APN # LAND USE APPLICATION # <br /> 'd� U ) OS _ (*? <br /> PHONE # 2 EXT. EMAIL P <br /> OS DISTRICT LO fAT !9N CODE <br /> ( ) 0 Ll <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C G � CHECK If BILLING ADDRESS <br /> J <br /> BUSINESS NAME PHONE # Ems• <br /> HOME or MAILING ADDRESS FAX #1 CQ <br /> o CD <br /> ( ) <br /> CITY /� STATE ZIP E A L <br /> BILLING ACKNOWLEDGEMENT : I , the undersigned property or business owner, operator or authorized agent of same , M <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 appli ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards , STA id FEDER S . <br /> APPLICANT ' S SIGNATURE : DATE : �pZz /C; <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ Kza <br /> ER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorion to sign is required i' / tle <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 /> rAy <br /> TYPE OF SERVICE REQUESTED : S <br /> COMMENTS . <br /> ,1 U N 2 7 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEE # : DATE : �� <br /> ACCEPTED BY : �:;' =— / 7riJ3 <br /> ASSIGNED TO : 46 !f EMPLOYEE # : DATE . <br /> Date Service Completed ( if already completed ) : SERVICE CODE : Cc <br /> P / E : <br /> Fee Amount : 3 � � [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 />