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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITYID# SERVICE REQUEST# <br /> �AOODD2-� � SQD085385 <br /> O ER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAM <br /> SREADDRESSC 1 5f�] <br /> Sbe.t Number Olmctlon CJ TJSIrro Name Ci ZI LeEe <br /> ME or LING ADDRESS (If Different from Site Address) <br /> XO <br /> Street Number store Hama <br /> CRY STATE ZIP <br /> PHONE#1 F". APN# LANDUSE APPLICATION# <br /> (20;)2 - <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^Tn �n <br /> CHECK((BILLING ADDRESS <br /> PHyl+e <br /> � <br /> BUSINESS NAME^ n %JJ,� <br /> MM or UNGADD�R.EC. FAX# <br /> ( ) <br /> CRY STATE CR 2:IP 9522a <br /> BILLING ACKNOWLEDGENIENT: 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,PTATE Vd FID)RAL laws. o, n <br /> APPLICANT'S SIGNATURE: Q / DATE: �Q <br /> PROPERTY/BCSINFSSOWNER❑ OPERATOR/NIANAGERM- OTHER AUTHORIZED AGE\T❑ <br /> /f APPL[cAwisnotthe BLLLLVGPARTY proofofauthadatfon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: 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 environmcntaVsite 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: 24%COMMENTS: Gnpr� ��` <br /> JUN 0 9 2022 <br /> SAN JDAGDIN COUNTY <br /> ENVIRONMENTAL <br /> REALTF DEPARTMENT <br /> ACCEPTED BY: NA EMPLOYEE#: DATE: �O-R-ZZ <br /> ASSIGNEDTO: vr1 EMPLOYEE#: DATE: �r <br /> Date Service Completed (if already completed): SERVICE CODE: I Q � PIE: CIO <br /> Fee Amount: S a _ Amount Paid � ' Payment Date L vii <br /> Payment Type 15 M Invoice# �Ile�c# l/ l� Received By: <br /> EHD 48-02-025 ! SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />