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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SP- `8- a� 3 <br /> OWNER/OPERATOR <br /> Mn in- 1n � n c)1 cc C CHECK If BILLING ADDRESS <br /> FACILITY NAME H \ P J <br /> SITE ADDRESS U I /D Q �' I O q if <br /> Street Number Direction V Street Name Ci ZIp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1:51M q I 1�) l n P-eC� <br /> Street am <br /> Street Number <br /> CITY 1 STATE ZIP A 9-c53 Q <br /> PHONE#1 1 En. APN# LAANND USE APPLICATION# <br /> P-09q-�21 +?e- 35 <br /> PHONE#2 ExT. EMAIL BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` <br /> Y I G n � � n Q I Cl c CHECK if BILLING ADDRESS <br /> BUSINESS NAME I J �' I� I J P # /I—Q�� n �E <br /> HOME Or G A[`D1RESS ` FAX# <br /> 11 U P—C ( ) <br /> CITY O STATE Cly- ZIP C]5=7�✓1`n I EMAIL <br /> 81LLING ACF( OWLEDGEMENT: 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 FEDERAL laws. Q/ n <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 2s soon 2s It Is available and at the same time It Is provided to me or my <br /> representative. P <br /> TYPE OF SERVICE REQUESTED: r CC)cl \C�V� C�C�R..c_(c SEC T <br /> QIJ <br /> COMMENTS: A/G <br /> /i U ?023 <br /> "S"ZRONMEN UN1Y <br /> h�Er'gRTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: (?j(6 <br /> ASSIGNED TO: C EMPLOYEE#: DATE:QDG . t-:A 12 3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: \(o(t, , <br /> Fee Amount: ��(;. Amount Pai 4,?6 rj� Payment Date <br /> Payment Type �- Invoice# Check# '(D`7342 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />