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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> [h�6 0 P6n�mL__ <br /> OWNIOP TOR <br /> CHECK If BILLING ADDRESS <br /> FACILI' AME (aVa f I N <br /> $`TE !t KESS C� � <br /> ll•Z Streel Number Direction ( 3lrlerName C <br /> HOME or MAILING ADDRESS (If Differentfrom Site Addr ss) <br /> Street Number Street Neme <br /> C TY STATE <br /> cad <br /> PHONE#1 Er. APN# LAND USE APPLICATION# <br /> ( ) — S <br /> PHONE#L EaT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR e CHECK if BILLING ADDRESS c� <br /> BUSINESS NAME <br /> 9 PHL_O(NJE'# Gr'/ <br /> Z01 (^ <br /> HOMorMLINGADDRESS A L FAX# E'tT <br /> t ) <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,STA"'E n DERAL laws. / �J <br /> PPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUsrNESS OWNER❑ OP R T R MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPL/CANT is not tine 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 enviroamentaVsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is availalWMENghe time it is <br /> provided to the or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Iran 0 Ap �j� vS�'� <br /> V 'l/ V tNf 6 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> CjLtj I i h the rte /IS �fi D� Zoq ) (ol(v-3o <br /> ACCEPTED BY: ra EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE �g DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /"I I PIE: IL/Q2 <br /> Fee Amount: Amount Paid I s-' Z_ Payment Date 3 6 2 z <br /> Payment Type IIS Invoice# Check# /r l Received By: <br /> EHD 48-02-025 I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />