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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r <br /> SERVICE REQUEST P1105'I 0011, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SP-W81569 <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> , <br /> *Iry <br /> AGILITY NAMF11 <br /> /�� I <br /> SITE ADDRESS r �/ <br /> Street Number Direction 1�J(v Street Name city Zip Code <br /> HOME or MAILING AD RESS (If/Different from Site Address) <br /> Street Number (G'l/A-StreeTiame <br /> CITY STATE ZIP <br /> b lSUNom\ C'�"7 <br /> PHONE#1 EM• APN# LAND USE APPLICATION# <br /> PHONE#Z Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> U CHECK If BILLING ADDRESS <br /> BUSINESICNAME PHONE# EXT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITYSTATE ZIP EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized age t 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 peyformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: �^I DATE: /- ,�`/ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MAN ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is Ot 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 infor d ation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provideif, my <br /> representative. ` R <br /> TYPE OF SERVICE REQUESTED: S�'A ` Sa L ct-w- - I�U <br /> COMMENTS: 1'1F U5 <br /> FvIIJO �O2�j <br /> N Ely /RQUiNC <br /> NT <br /> ACCEPTEDBY: N,\Ck""�e M EMPLOYEE#: DATE:O'k 115 -. 4 <br /> ASSIGNED TO: EMPLOYEE#: DATE:v J <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: c(D <br /> Fee Amount: `(�Z Amount Paid I bD/ Payment Date �2 <br /> Payment Type Invoice# Check# 17 3725 �o Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> J <br />