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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT W,u 1 �2�CJ <br /> SERVICE REQUEST 1 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �2zA �m� aCo 9 SRm(2)8-7449 <br /> OER/OPERATOR <br /> , CHECK If BILLING ADDRESS❑ <br /> Tr <br /> ❑ <br /> ACIUTY NAME <br /> SITE ADDRESS ///►✓� r /� �]T <br /> Street Number I Direction 9trLet ame �Clt ✓ ZIP Code <br /> HOME fVG ADDRESS (If Different from Site Address) <br /> Street Number ✓ Street Name <br /> CIT ST TE ZIP <br /> YL4, G 59-1 <br /> PHONE#1ExT. APN# LAND USE APPLICATION# <br /> (9 IG) (v - .3� V-( A;ShA <br /> PHONE#2ExT. MAIL BOS DISTRICT LOCATION CODE <br /> WO) Sq - moa Chan ez 1 , <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR A ', 5 N <br /> ',�— CHECK if BILLING ADDRESS <br /> BUSINESS NAM f PHONE# ExT. <br /> -L 7- I� �-G�-{ - 3q H <br /> HOME or MAILING ADD ESS FAX# <br /> CITYI A STATE ZIP Q S G� Gt EMAIL <br /> VJ ` ` 1 q V G— <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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _ DATE: 7/2 ,3 <br /> PROPERTY/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 provided to me Or my <br /> representative. <br /> A I— <br /> TYPE OF SERVICE REQUESTED: pC(.f r & - �I v <br /> It <br /> COMMENTS: V AF0 <br /> SA At NOV ?023 <br /> NEA TND pMEN��NTY <br /> ARTM,E <br /> ACCEPTED BY: q EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1Z <br /> C— EMPLOYEE#: DATE: 2 <br /> 3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I L <br /> Fee Amount: Amount Paid /('2 00 Payment Date �� 3 <br /> Payment Type Ul Invoice# Check# 7,2- (P 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />