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SAN JOAQUIN COUNTY ENYHRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SQ �ogsy ►� <br /> OWNER IOPERATOR <br /> u� CHECK If BILLINGADORESS0 <br /> C1/� � I C <br /> FACILITY NAME'1�ti G 6-7Y--fI �ti ► <br /> vI <br /> SITE ADDRESS U v V r• S�v CGP q 52.16 <br /> be, I D rl ec ton � Street Name CI Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONEP1 E%r' APN# LAND USE APPLICATION# <br /> 0X10) 2,4 ►- N <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOF�\�, <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �I D' 1 ��I I ( PH �# Ex' <br /> HOME Or MAILING ADDR S'M r I G J FA%# <br /> CITY 5i`Z✓/ V) T E ZIP -5-Z / <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 FEDWL IoW / <br /> APPLICANT'S SIGNATURE: DANA:'- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPP/JCANT is trot the B7LLIN0 PARTY 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 environmentallsite assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at,.t11C$pp7g.tilaP.- is <br /> provided to me or my representative. �+�i tY1CIV t <br /> TYPE OF SERVICE REQUESTED: y L,yt,t G� <br /> COMMENTS: JUN 16 2022 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> ,I HEALTH DEPARTMEN <br /> ACCEPTED BY: I/t/" EMPLOYEE#; DATE: —I0-22 <br /> ASSIGNED TO: SEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �) 1 P I E: <br /> Fee Amount: , 152 _ Amount Paid (sa — Payment Date <br /> Payment Type\/ 15 f Invoice# _Ch6c-k#'��2 ?l- -,�-b 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> PRo5-0'�7q� ,S <br />