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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 0? v`13 <br /> OWNER/OPERATOR <br /> �� CHECK If BILLING ADDRESS <br /> FACILITY NAME � O WtA C a m (/ipp <br /> SITE ADDRESS <br /> J I-)— A A Street Number Dire&on Wily),^1 Street Name ""�G Zi Coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) . <br /> r <br /> Street Number GLIn Street Name <br /> CITY LISTATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ,✓ <br /> ( q n- iLictu <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR it SERVICE REQUESTOR <br /> REQUESTOR <br /> rawa G r CHECK If BILLING ADDRESS <br /> BUSINESS NAMEL_ PHONE# EXT. <br /> U CMAM Li a to <br /> HOME or MAIL)JG ADDRESS FAX# <br /> J fJ ( ) <br /> CIN STATE ZIP <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 <br /> or activity 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. 7 <br /> APPLICANT'S SIGNATURE: DATE: 12-13112024)12-1 J I 1 2U <br /> PROPERTY/BUSINESS OWNER U OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIcANT is not the B/LLINGPARTY 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at th11time it is <br /> provided to me or my representative. /� <br /> TYPE OF SERVICE REQUESTED: I C.. 1 <br /> COMMENTS: 3 <br /> e- ,10 <br /> H � Qou <br /> '70�D p4" ti qlN� <br /> 4fe <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: O <br /> ASSIGNED TO: V _ EMPLOYEE#: G� )— DATE: ihf <br /> '-o <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: d3 <br /> Fee Amount: 2�� Amount Paid? <br /> Q-)10 Payment Date J J t <br /> J <br /> Payment Type Invoice# Check# Receivd By: <br /> EHD 48-02-025 <br /> REVISED11/17/2003 SR FORM(Golden Rod) <br />