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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> JUUrGcI� D2 S r\ 5 v <br /> OWNER/OPERATOR <br /> ) <br /> `.yam `� — C� CNECKIf BIWNG ADDREeS <br /> FACnITY NAME -r ` 1 C{ �� f <br /> SITE ADDRESS W l�lrlYle. �ZC\ Tra qS�)0(—I <br /> 5CD1 Street Number Direction street Name Do Catie <br /> HOME or MAILING ADDRESS (If Different from Site Address) as rCl '�A . <br /> asStreet Number Iatree Nama <br /> CITY STATE zip <br /> rp— 1� <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 EICT. BOS DISTRICT LOCATION CODE <br /> ooq) a35 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> \ ^ <br /> CIO <br /> CHECK If 81WNG ADDRESS❑ <br /> BUSINESS NAME ` l/t I PHONE# r -_�O Ems• <br /> UrCXA k (a C9 <br /> HONE Or MAILINGADORESS FAX# lU <br /> e9r)CD ( ) <br /> CITY C a �p STATE LP <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 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 FEDERAL laws. /� a,-� <br /> APPLICANT'S SIGNATURE: Q��'� �Q� v, \ DATE: � ,a�� v�Oa•c� <br /> PROPERTY/BUSINESS OWNER'W OPERATOR/MANAGW❑ OTHERAUTHORIZED AGENT❑ <br /> IfAPPZTC4,VTis not theBILLGVGPAeTY 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: C <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> JUL 2 8 2022 <br /> IAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L'\/\ `('� t.eS EMPLOYEE#: DATE: <br /> Date Service Completed\(H already completed): SERVICE CODE: Pt E: <br /> Fee Amount: 1 S V r Amount Paid Payment Date Z S L <br /> Payment Type Invoice# fCh�ek# T ZGto Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />