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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT (�e \./u <br /> SERVICE REQUEST r�eec1--z R2 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> \A 0 ? 7421 <br /> OWNER/OPERATOR4 / _ CHECK if BILLING ADDRESS❑ <br /> 161 <br /> FACILITY NAME /i f C a -Z9 <br /> SITE ADDRESS 1T <br /> �trbet Number direc it on /�/( Street Name City Zip Codc <br /> HOME or MAILING ADDRESS (If Different from Site Address) ; / / �l �Sr7� <br /> Street Number treet Name <br /> CITY ^ STAT ZIP _ <br /> /7 �,Zw7 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (004 ) s13- 036cl <br /> PHONE#2 ExT. EMAIL Y BOS DISTRICT LOCATION CODE <br /> jC7 <br /> 5,0 <br /> CONTRACTOR/ SERVI E REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <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 laws. <br /> APPLICANT'S SIGNATURE: 4(0/ f'c"rz �; 'rez DATE: �� Z-3 <br /> PROPERTY <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 /> TYPE OF SERVICE REQUESTED: RECFIVFn <br /> COMMENTS: <br /> NOV 14 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C �C' (1 , , \ EMPLOYEE#: DATE: 11 <br /> _ 14 <br /> _200 <br /> ASSIGNED TO: p EMPLOYEE#: DATE: I 1_ 1 oa <br /> Date Service Completed (if already completed): SERVICE CODE: PIE. I O <br /> Fee Amount: \ — Amount Paid / Payment Date t( l 2-V L <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03122123 <br /> PR V, <br />