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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L0C(,1Nol M� ,1 U(�3v�3 S Uu SItn3 <br /> OWNER/OPE TOR M^ ` <br /> t 1'�T-&� J\ CHECK If BILLINGADDRESS� <br /> FACILITY NAME Yl r <br /> EcOYIv Lvvl <br /> SITE ADDRESS3511 N X53 <br /> 3x11 N T'rmc�) -�"O� 7"rT.�c�� -7 <br /> 're' 9C &V d Street Number Direction Street Name city21 Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 10913 Pd f' k o Cir Street Number Street Name <br /> CITY D STATE ZIP <br /> F—P14ck0 (0V.Gvc;' O <br /> PHONE#1 EXr' APN# LAND USE APPLICATION# <br /> (;1,09 ) bol - 6082 Ca I <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Avm4 ^ I <br /> Ir CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C—Cono (_ <br /> HOME or MAILING ADDRESS FAX# <br /> IC&q oro-Ito CtY ( ) !] 0 <br /> CITY 4� ECMO far oV STATE C4 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. <br /> APPLICANT'S SIGNATURE: � DATE: AIA v i J �S 2o2Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLicAAlris not the BfLLxGPARTY 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 enviroamental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: (� (� RF <br /> COMMENTS: <br /> APR 15 2022 <br /> °RQulvCou >Y <br /> yTN fAL <br /> DE AR M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Ir 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: J <br /> Date Service Completed (If already completed): SERVICE CODE: P/E: <br /> Fee Amount: 'Q Amount Pa' `JoC �D Payment Date <br /> Payment Type Invoice# Check# (� Recei ed By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Li Of <br /> r 1� V 1 <br />