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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ]A, <br /> UD rS <br /> SITE ADDRESS (- � <br /> 441 Z Street Number Dlrection ^'v v�' i <br /> Hom,E MAILING ADDRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITYIto � �� STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ()m -�-I :�> <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR vi <br /> J I l[I r' �/J S CHECK If BILLING ADDRESS <br /> BUSINESS NAME pl(tvV yS V PHONE# �I / ExT. <br /> H�M�gMAILIN ADDRESS Cy,� q!�2 O 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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SATE and FEDER L laws. / <br /> APPLICANT'S SIGNATURE: DATE: 05 2I12 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/M GER ❑ 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 assessmenp�malior to the! <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pr4id or myi <br /> representative. n L F Nr <br /> TYPE OF SERVICE REQUESTED: `• Ce CVea � COVES WC�l L�'10�� NAR <br /> COMMENTS: CT 20 <br /> Z, !O QU��C ?4 <br /> 4�ryo°pgR <br /> -44 <br /> r4fFNT <br /> ACCEPTED BY:by EMPLOYEE#: DATE:-3I'2-Z,2ZZLA <br /> ASSIGNED TO: CWiC✓(dQ EMPLOYEE#: DATE: 31?C �'ZmZy <br /> Date Service Completed (if already completed): SERVICE CODE:Q`L P I E: <br /> Fee Amount:t`(o2 oo Amount Pai 16,?, w Payment Date Z <br /> Payment Type Invoice# Check# ?gt�rjzg Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 P^ b A n O 1 W <br />