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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 <br /> SITE ADDRESS <br /> C- i• <br /> 2-a e-- - <br /> Street Number I Direction I Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> W16- 4110 -Z:f/3 <br /> PHONE#2 EXT. EMAILBCIS DISTRICT LOCATION CODE <br /> ( 1 OBD • G� IV4lL- • (• <br /> CONTRACTOR / SERVIC REQUESTOR <br /> REQUESTOR /y <br /> '� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ! ,..— v( n PHONE# / -- EXT• <br /> HOME or MAILING ADDRESS elszlz)o 6�e ��Z, Gq 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 applic ion a th the ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE n F A l w <br /> APPLICANT'S SIGNATURE: ," DATE: ® Z?b <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAR proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: hen 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: <br /> COMMENTS: JU <br /> l 9 2023 <br /> RQUIiyC <br /> yA.ll�p6MFiyT�Al7?' <br /> ACCEPTED BY: I • CISCC.V U EMPLOYEE#: Q$Cos DATE: & ZQ 2 3 <br /> ASSIGNED TO: kj�6,& t�eC�Y G 0. EMPLOYEE#: (p2 DATE: GJ ZGj l 23 <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 P/E:v�ov <br /> Fee Amount: 3 ytob Amount Paid Payment Date �3 <br /> 0 <br /> Payment Type 0WA, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />