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SANJOAQUIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ^����QUEST <br /> A000�2-c� I S cam. 3 <br /> MOR OPERATOR CHECK If BILLING ADDRESS❑ <br /> FAcILITY NAM <br /> SITEADORESSl <br /> street NumbLr plmctlon W CJ VStrea Nama Ci Z1 Code <br /> ME Or ILING AAD�DRESS (If Different from Site Address) <br /> Xoji' Strtet NumAer simet Name <br /> Cm STATE LP 22a:- <br /> PHONE 91 Err. APN III LAND USE APPLICATION# <br /> 120,►2 - <br /> PHDNE#2 EaT• SOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> GI t , `-V ► l CHECK If BIW NG ADORE55 <br /> BUSINESS NAME PNyI+e _ E><r <br /> L[1j/ l <br /> M�O! UNG ADDRE FAX <br /> t ) <br /> Cm STATE ZJP G <br /> BILLING ACKNOWLEDGENTEN"17: 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 /> oractivity 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 - d FID RAI,laws. o, <br /> APPLICANT'S SIGNATURE'� �> I,--- DATE: � 4 ! I <br /> PROPERTY/BCSixEss OH:NER❑ OPERATOR/If1A.NAGERML OTIIER AUTHORIZED ACE\TO <br /> /jAPPL/CANT is not the BILLINGPARTY proofojauthorlwion to sign is required Tirte <br /> AUTHORIZATION TO RF,LEASF, 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 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DGPARTMENr as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REDUESTED: PAYME <br /> COMMENTS: <br /> JUN 0 9 2022 <br /> ,AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH OEPAHTMENi <br /> ACCEPTED BY: I)A EMPLOYEE#: DATE: <br /> ASSIGNED TO: Dp EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERYICECODE: I Q � PIE: <br /> Fee Amount: 5 Go Amount Paid 152_ Payment Date Gl 27i <br /> Payment Type1,5 ITI Invoice# �hooea<��rc# ` l�l1 1 Received By: <br /> EHD 48-02-025 t`"'kii, l 1 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />