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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TCECREt4/Y -SAIEs � tl��j <br /> OWNER/OPERATOR <br /> Rot) S ^ I I CHECK If BILLING ADORESS� <br /> FACILITY NAME 5COO ^S <br /> $READDRESS l� �./J <br /> 230o Street Number Direction PCc:IQ'lc atreef Name S� I CI CJ'Ji&.? <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> e0kVCTA P D . Streal Number Street Name - <br /> CITY 0t /� � _ <br /> STATE ZIP <br /> I �s / <br /> PHONE#f - EXT. APN# LAND USE APPLICATION# ..7 <br /> (w ) 99,5-1s00 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# . <br /> CITY STATE ZIP <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 drat 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. <br /> APPLICANT'S SIGNATURREE:: �'1.� DATE: <br /> PROPERTY/BUSINESS OWNERW OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anti same time it is <br /> provided to Ire or my representative. � <br /> K 11111 i) <br /> TYPE OF SERVICE REQUESTED: /vj� <br /> COMMENTS: JUN 2 42022 <br /> 63 &%VIRJOAOUNv COU <br /> MST h�f <br /> "Milo <br /> ACCEPTED BY: I A �� EMPLOYEE 5 DATE: 60 2, Z2 <br /> ASSIGNED TO: VVArl( <br /> l EMPLOYEE 3 DATE: �Y 2 22 . <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: /� 7 <br /> Fee Amount: '�U Amount Paid Payment Date <br /> Payment Type Invoice# Check# O O Received By: <br /> EHD I SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11/17/2003 <br />