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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ss�bit ! LP-9 1=� ZSIy 00�5U1� <br /> OWNERI OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Stoat Numlrer Directlon Street Name C ZICode <br /> HOME or MAILING ADDRES (t(f`Differentfrom Site Adtdras^a)7 <br /> v o /d 0 J Street Number street Name <br /> Cm STATE ZIP ���^/� <br /> fS <br /> PHONE#1 Ev, APN# LAND USE APPLICATION# <br /> (2-0) '521-2Za9 <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> to CtiC�SCJ � r {�'I•�\.�r` CHECK If BILLING ADDRESS� <br /> BUSINESS NAMETPC'. 4 ���. P20# -22-09 <br /> Exr. <br /> HOME or MAILING ADDRESS FAX# I <br /> z 7 t SCIS ( ) <br /> CITY %r,4-,- STATE C-9 zip .7 5;- <br /> BILL G <br /> BILLING AC OWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific1NVUtONMENTAL 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: r 16–22-- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERgogo OTHER AUTHORIZED AGENT El <br /> /fAPPL/CANT is not the BILLIM7 PARTY proof of authorization to sign is required Tit[, <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 atathhfl same time it is <br /> provided to me or my representative. /�+q Y <br /> TYPE OF SERVICE REQUESTED: EI V <br /> COMMENTS: <br /> MAR 16 2022 <br /> S. NVIRO t11N COON <br /> HEgLTH DE,4)MAL Ty <br /> ACCEPTED BY: 1 r-\YNo`re EMPLOYEE#: DATE: 3 -l l__ 'L <br /> AsSIGNEDTO: � ^Y\O-, EMPLOYEE#: DATE: 3 - 1 `0- 2- 2 <br /> Date <br /> - V- <br /> Date Service Completed (if already completed): SOMCECODE: b I P/E: 1 <br /> Fee Amount: SZ— Amount Paid '5;� D-D Payment Date 3 22 <br /> Payment Type �� Invoice# Check# l 4 fbl,. �2 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> P�o�� 233 S <br />