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Type of Business or Property FACILITY ID # <br />COtA^ 1$ <br />Direction Street Name City Zip Code <br />Email BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />■ s Abov e <br />Business Name Ext. <br />Home or Mailing Address <br />City State Zip <br />Type of Service Requested: <br />Comments: <br />Employee #:Date: <br />Employee #:Date: <br />Amount Paid <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />Owner / Operator <br />WNAMEx—/ <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />SERVICE REQUEST# <br />« <br />Check# <br />Street Name <br />ZipState <br />CA <br />Land Use Application # <br />Service Code: [ <br />Payment Date <br />Check if Billing Address EJ <br />Check if Billing Address D <br />Facility Name 7—/ / <br />*______t~l ^J/?/;^/e/7^e <br />Site Address <br />1__________________Street Number <br />Home or MAILING Address (If Different from Site Address) <br />Phone # <br />J__L <br />Fax# <br />J__)_ <br />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 />I 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. <br />APPLICANT'S SIGNATURE^. f y^p DATE: <br />Property I Business Owner-TLI 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 as soon as it is available and at the same time it is provided to me or my' <br />representative. <br />| ((pots <br />Received By: <br />___________________Stroot Number_______ <br />Si <br />APN# <br />fyow-> <br />Bus- <br />Phone #1 . ext. <br />Phone #2 ext. <br />( ) <br />Accepted By: <br />Assigned™: XacLtcaovt. <br />Date Service Completed (if already completed): <br />Fee Amount: <br />Payment Type