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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />SGI C'J <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST# <br />S6-1' oo2y 633 <br />OWNER / OPERATQR <br />A { <br />\ �/ <br />\ <br />CHECK If BILLINGA0DRE55� <br />FACILITY NAME, <br />(A)GI, 1'e— ( <br />FAX# <br />( I <br />CITY e U <br />SITE ADDRESS IZ(` <br />Street Number <br />Direction <br />�lakK TN <br />Street Name <br />Date Service Completed (if already completed): <br />K0 cJ'{ri <br />CRV <br />953 S <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) I'4 Z_K <br />Street Number <br />Fee Amount: <br />W Q \Qd 1 t I <br />Street Name <br />1 <br />CIN �oVe C ` <br />J--�(� <br />— <br />'j <br />STATEC/, ZIP q � J 5 0 <br />PH taE F1 Exr <br />Gf 2 , T <br />Payment Type V,S <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EKr• <br />( ) <br />Received By: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />SGI C'J <br />BUSINESS NAME <br />COMMENTS: <br />PHONE # EXT. <br />AUG o JC 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />GC <br />l <br />HOME Or MAILING ADDRE S <br />a <br />(A)GI, 1'e— ( <br />FAX# <br />( I <br />CITY e U <br />STATE ZIP Ct S9 <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 _land FEDERAL laws.. , 1 <br />APPLICANT'S SIGNATURE: (' �t U M1� f SG I / C` V 0 DATE: S <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT E3 <br />IfAPPLICANT 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 <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 ag j(y samee it is <br />provided to the or my representative. YAY MEN* <br />TYPE OF SERVICE REQUESTED: P)gy') <br />IJ CA 112A-k&i C_ <br />COMMENTS: <br />AUG o JC 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Ir` 1 <br />EMPLOYEE #: <br />DATE: C; <br />2 <br />ASSIGNED TO: \ <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S2 , <br />P / E: (nO I <br />Fee Amount: <br />(� i <br />Amount Paid <br />— <br />Payment Date <br />` 2— ) <br />Payment Type V,S <br />Invoice # <br />Check# <br />Received By: <br />EHD 48-02-025 C d we =H— 12 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />