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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/O ATOR <br /> G` \ CHECK If BILLING ADDRESS� <br /> FACILITY NAME �J p5 -�.1 <br /> SITE ADDRESS II I�t/) S AgVI� <br /> `sheet Number Directlon I` Streelt Name I I 2 Co✓deo <br /> HOME or MAILING ADDRESS (If Different from Site Add ess) 2 <br /> 2 W� Street Number Street Name <br /> CITYr� ,to STATE IP �r-r— <br /> (NONE,fvl; ApN# LAND USE APPLICATION# J� <br /> PN0N(,NEE##2 ' r T• BOS DISTRICT LDCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �^- 1. <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME IL425 D'(J/_'OfV PFJQNFr�) �`6?C'��Ex . <br /> HOME Or I GA RF t LFAX## <br /> rra � z ( ) <br /> CITY TATE ZIP 12151a <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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 identifi on this form. <br /> I also certify that I have prepared this application and tyat the work to be performed will be done in accorda ce with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE- <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER❑ OPE OR/ AGER ❑ OTHERAUTHORIZEDAGENT❑ <br /> IfAPPL/CANT is not the B/LLING PA Y 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Hokj.t -Ind ConSiAdhOli RECEIVED <br /> COMMENTS: <br /> AA z 7 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: f d r EMPLOYEE#: ^ DATE: <br /> ASSIGNED TO: lL � EMPLOYEE /04 DATE: <br /> Date Service Completed (if already completej): SERVICE CODE: P/E: /V03 <br /> Fee AmonCj Amount Paid /s-Z Payment Date <br /> Payment Type CC k Invoice# Check# O 31 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />