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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> =GS 'Rrv/� L I -40oag39 S M55T <br /> OWNER I OPERATOR <br /> / Y (/U/1 X ✓V1.. 'Ln CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS G/UYrtiG/G SfC <br /> �o.7 !N �/ ✓IUL�C.�Gn 9121G <br /> Street Number Direction Street Name �l Cil ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 y 2 S Street Number Street Name <br /> CITY / STATE ZIP <br /> C d1t rti 6r q <br /> PHONE#t EST• APN# LAND USE APPLICATION# <br /> (7) o) Ll7,2_ �130 <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME // 1 PHONE# E'•T. <br /> {�G (U[�;-i /a�J. /&VY'rnn-r .2611 ) t172. - 910/ <br /> HOME or MAILING ADDRESS FAX# <br /> ko 3&1 N e/ N / ( ) <br /> CITY ('� STATE ZIP pr2/GL <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 HEALTFI 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 wilt be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> I9aPRAPPLICANT'S SIGNATURE: � Z DATE: 07/.2-7/9,;'- <br /> PROPERTY <br /> OPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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 to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is av�iacne time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: JUL 2 7 2022 <br /> COMMENTS: /�Ilje . of aUJntCsh(p SAN JOAQUIN COUNTY <br /> �Y 1(M t V ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> UkAt SPNAt `tkMir'�,'Z 'v UP ins 0/7 (2 CO (P-3.0 I <br /> ACCEPTED BY: LOIAM S. <br /> EMPLOYEEqq DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2� <br /> Date Service Completed (if already completed): SERVICE CODE: P 1'E: <br /> Fee Amount 00 Amount Paid Payment Date L' — <br /> Payment Type nvoice# C # 7�- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 �' V l•"^�2� <br />