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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business roperty FACILITY ID# SERVICE REQUEST# <br /> 10-5 k <br /> OWNER/OPERATO� <br /> © O &46 CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME O 5 a Perm�D^�SITEADDRESS tw•�10 Lo � Q�aip <br /> 13 13 Street Number Direction Street Name D Zi Code <br /> HOME or MAILIN ADDRESS (If Differgnt fro Site Address) �Uf� m� ��J�p�/ I \l <br /> �y l3 mo 0Iv 1ViGWw1/VV 11 Str{eet Number l�1 t�6 st'�et NakmJe' <br /> CITY /v l / �0 STATE ZIPC144 q,6 3 <br /> PE#1 �( EXT. APN# LAND USE APPLICATION# <br /> X,) UqU- o�'I- ,� <br /> PHONE#2 Ext. EMAIL BOS DISTRICT LO ION CODE <br /> Cg-,cai� . o ,M <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR v <br /> `Ci , ( 1 CHECK If BILLING ADDRESS❑ <br /> In I t <br /> BUSINESS NAME i PHONE# Exr. <br /> J ( ) <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 thy work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE an F DERAL I <br /> APPLICANT'S SIGNATURE: fi) DATE: <br /> PROPERTY/BUSINESS OWNER L OPERAT /MAN R 43 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 environrnental/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. J p <br /> TYPE OF SERVICE REQUESTED: l VI 417 P&�7L <br /> COMMENTS: <br /> 2,; <br /> CV J SAN JOAQUtty COU <br /> NEq�HI��IVMR �TY <br /> T <br /> ACCEPTED BY: EMPLOYEE#: if DATE: :;?; 1'1L1124 <br /> `1 L1 Z <br /> ASSIGNED TO: t f L (�� EMPLOYEE#: !� DATE: r Z <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount: Z Amount Paid � Payment Date <br /> Payment Type Invoice# Received By: <br /> � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />