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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-A 0002-S� SWI co�? <br /> OWNER/OPERATOR ^ ,, /°!0 n ���� �/ —C-(j/ �t r� ❑ <br /> '( � fV CHECK if BILLING ADDRESS <br /> FACILITY NAME './'�fA✓�nl„S �D QS <br /> SITE ADDRESS L17:1- 1 1 V2 i1 <br /> Street Number Direction treet Name -t W1CI`t' Zip Code <br /> HOME or MAILING ADDRESS (If Different/fAddress) <br /> _S1 /J I v ro Site Street Number Street Name <br /> CITY �� STATE ZIP <br /> PHONvill LAND USE APPLICATION It <br /> � ) o- � 7 / <br /> PHON �7 Exr. BOS DISTRICT LOCATION CODE <br /> TN <br /> ) U / <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ��/ CHECK if BILLING ADDRESS <br /> BUSINESS NAME� ���U•f/\�� Ezr. <br /> - <br /> o- 7 / <br /> HOME or MAILING ADDRESS 37S6 IV/Cm&/J 9L FAx# <br /> CfrYt- STATE C4 ZIP qCIA) <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 thi ap 's tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar, T_ and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 0,3-� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT it not the BttLtlyGPAR TYproof dfauthorization tosign isrequired 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same titheit is <br /> provided to me or my representative. " ""WENT <br /> COMMENTS: <br /> TYPE OF SERVICE REQUESTED: C�ct.vl0� OuJVIQ,(QSL�,Q„ Tw� Cl�/l.s�..l-h�k,. <br /> COMMENTS; t7� O � MAR p 1 <br /> 2022 <br /> SANJOAQU1N <br /> H�ENWROG Litton, <br /> ILTH D P E NT <br /> ACCEPTED BY: Vl EMPLOYEE#: DATE: / —O'_'22 <br /> ASSIGNED TO: � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Do I <br /> P/E; t 0 <br /> Fee Amount: )�2� Amount P ' /5 �/ Payment Date //?� V L <br /> Payment Typ Invoice# Check# /37 7 3,576 Rec ived By: <br /> EHD 48-02-025 (��� (�,\(oL.,2 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Y <br />