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SERVICE REQUEST# <br />Site Address er <br />Street Numbar <br />CITY <br />7757/ <br />APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Ext. <br />CA <br />City State <br />Employee #: <br />Employee #: <br />Service Code: <br />Amount Paid <br />Invoice # <br />SR FORM (Golden Rod) <br />Phone # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />9^5 9/ <br />Zip Code <br />s <br />Direction <br />TC\&\CXX\ \Aa^75\6) <br />Home or Mailing Address <br />___________________ <br />Type of Service Requested: <br />Comments: <br />ua <br />Streel Number <br />Home or Mailing Address (if Different from site Address) <br />____________________ <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />Accepted By: (3 <br />Assigned to: <br />t ------- Payment Date <br />Street Name <br />Zip <br />Check if Billing address E3 <br />Check if Billing Address CJ <br />__________City <br />CoGJ «*• <br />State <br />C ft <br />Land Use Application # <br />PAYMENT <br />-------------RECEIVED <br />FEB I 0 2023 <br />_____ health department <br />_____DATE: z-7^23 <br />Date: - 2"5 <br />/lp//E7^o/ <br />V/-Y 2-^~ <br />Roceivod By: <br />Date Service Completed (If already completed): <br />Fee Amount: <br />Payment Type /?- <br />Type of Business or Property I <br />Owner I Operator <br />FAatlTYNAME-j^^^ ^£51 Zj L^/V9 y C <br />'i~ ftftDmoAJ <br />_____________Street Name <br />Requestor <br />________5oX\ <br />Business Name <br />APPLICANT’S SIGNATURE:---- ------------------------------------- Date: <br />Property/Business Owner EJ^ Operator/Manager other Authorized agent <br />// Applicant is nol the Billing Part}’, 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the San Joaquin Counts’ ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and al Ute same time it is <br />provided to me or my representative. <br />[TIC'L'NyflT/U HfrU-SE <br />Phone #1 ExT- <br />(■no S7g - g^7 <br />Phone#2 <br />() <br />Fax# <br />( )_______________________ <br />________________STtTE z"’ cvs.yn <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 Environments 1If.AI.TII Department hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that 1 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 Federai laws.