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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 vOftvl35 s� 00,g <br /> OWNER 1 OPERATOR <br /> I_1v r(D H1Gk rC 1 Tn \tu CHECK If BILLING ADDRESS <br /> FACILITY NAME RN 0, S C,\KF (J <br /> SITE ADDRESS (2 `� e I JOS f t l QS --TlDL�J"-) -C3-Fe A or S Z <br /> Street IN b¢r Direction Street Nama city21 Cotl¢ <br /> HOME Or MAIr AADDRESS (If Different from Site Address) <br /> 5 3Ar\��' �V v Street Number C Street Name <br /> CI.Y,�`,��� SR� �MN`\CC� STATE ZIP <br /> PHONE#1 Ez . APN# LAND USE APPLICATION# <br /> (CSO ) 2}1 30-LI `L <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (:�(b <br /> BUSINESS NAhu <br /> ME a , /( U�� l \ r "�� CHECK If BILLING ADDRESS <br /> ` M �\ C ` PHO E# E <br /> XW <br /> 0 IKN,�\ S eKFE ( Sq Z}1 304 <br /> HOME or MAILING ADDRESS FAx# <br /> S(^\� �R n-f K ( t <br /> CITY SOOT' A 5PlN ' *- ^To CNSCO STATE /b ZIP OCdD r <br /> BILLING ACKNOWLEDGEMENT: 1, 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 F WS. <br /> APPLICANT'S SIGNATURE: DATT: _ / (9 /xzJ <br /> PROPEKrY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTnER AUTHORIZED AGENT❑ <br /> f APPLICAAT 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 environmental/site assessment <br /> information to Ute SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the sante time It is <br /> provided to me or my representative. . ( PAYmphl <br /> TYPE OF SERVICE REQUESTED: ✓'�� C0 fj�AJ„ VV`, ce <br /> COMMENTS: vav�— nop o w'U /u <br /> OCT O 4 2022M JOAQUIN CO <br /> HNT��OE <br /> I� oive, aD uv� EN <br /> ACCEPTED BY: EMPLOYEE M DATE: 10 .22. <br /> ASSIGNED TO: EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: O [PI E: 01 <br /> Fee Amount: S Amount Paid �S� D Payment Date ID14 zZ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />