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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ?P'05L4u0 5 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> "':S R(1) <br /> OWNER/OPERATOR <br /> U-Muj <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME — VNV ,! CO �G4 <br /> SITE ADDRESS �i II((►►� 1 �ko �o / S - j v <br /> 1 Sheet umber Direction Street Nme Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i�442 W, Street Number Street Name <br /> CITYI STATE ZIP <br /> /1y c C 51ZI U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �1 <br /> �L�( (/ , I Jf�� CHECK If BILLING ADDRESS <br /> v�L 1 "t L;VIU Z <br /> BUSINESS NAME PHONE# EXT• <br /> HOME or MAILING ADDRESS FAX# <br /> U O Y Y ✓� V d O <br /> CITY STATE ZIP EMAIL <br /> CA <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 /> i <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, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (,tY �( d — DATE: 1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ THER 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: ', DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1/ <br /> Date Service Completed (if already Completed): SERVICE CODE: 2 P E: I <br /> Fee Amount: %' Amount PaidDD Payment Date /s 23 <br /> C� • <br /> Payment Type Invoice# Check# i�ZO 13� Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />