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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ?Q �SLf� �jZ2 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S12,cod' u Sip <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME — <br /> �v <br /> SITE ADDRESS <br /> il(jG ��CI�AOSG�S TS1��� �C{G1��/vt� <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) T C <br /> U S� <br /> I ('C Street Number treat Name <br /> CITY STATE C n ZIP G 1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 7 <br /> I ( <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> S'G5Co �Si�vc�Clt�G�LZNL C�I� <br /> CONTRACTOR / SERVIC 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 FED t laws. <br /> APPLICANT'S SIGNATURE: DATE: -2"I r 2,� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANA ER ❑ 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 ppxl(iQ�i t0 me or my <br /> representative. II�y rMEArr <br /> TYPE OF SERVICE REQUESTED: TbD6 qkdLA= clo, 'VED <br /> COMMENTS: N Z 9 2024 <br /> SAN <br /> OROJAQNiN COV NT y <br /> HATH CEARTMENT <br /> ACCEPTED BY: IM, EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SJ4: 1ERVICE CODE: O� t PIE: <br /> IVA <br /> Fee Amount: ' Amount Paid 6,? Payment Date �2-`21Z <br /> T <br /> Payment Type Invoice# Check# 17 SS73)- C Receive By: <br /> ri <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />