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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SROO <br /> OWNER 1 OPERATOR n <br /> I1 ro f-� 1 A cA� o n �� C I ri Q I'�o J r I U e- CHECK If BILLING ADARE55❑ <br /> FACIUTY NAME l/V fff / 11 <br /> SITE ADDRESS <br /> Street Number Direction Street Name City -T Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) e P p rT 1 - <br /> [' Street Number �L Street Name <br /> CITY ST TE zip <br /> �,C n �� 95-2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (VT 210 Por -cc`— <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> (55 ) (952.-� `1(0 �— A(es mRxlGarlrts5)br, . cor-PI <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 the work to be performed will be done in accordance with all SAN JOAQUIN' <br /> COUNTY Ordinance Codes, Standards, STATE and FE L I ws, <br /> APPLICANT'S SIGNATURE: DATE: 1 - -7 - 2 <br /> PROPERTY I 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 environmentalisite assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It i5 provided to me or my <br /> representative. lr <br /> TYPE OF SERVICE REQUESTED: 12layl CkeCK <br /> COMMENTS: D <br /> QSAN Jop� <br /> h EN�'Rp�ife U <br /> Tli oe Nr Nt <br /> ACCEPTED BY: EMPLOYEE M DATE: {l 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: I ! Z <br /> Date Service Completed (If already completed): SERVICE CODE: 132 3 IP/E: <br /> Fee Amount: 42(Q Amount Paid ke — Payment Date 23 <br /> Payment Type Invoice # Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />