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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2S �36o q;U <br /> OWNF,R( O( PE1 R/ATOR ye � <br /> CHECK If BILLING ADDRESS <br /> / c <br /> FACILITY NAME <br /> SITE ADDRESS <br /> SIL �/lNl� Jry I�fC_ J N _1 J <br /> �. Street Number Olreetlon Street Nama t ZI Code <br /> HOME or MAIL[ G ADDR SS{�([f Di er t from to Address) <br /> J "� Street Number Street Name <br /> CITY j W JWP STATE ZIP <br /> Pft <br /> HONE#j V— I v APN# LAND USE APPLICATION# <br /> (�08 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,.,/II lv\! n 1 _ I�r� <br /> I(r Il�,rj ^v W CHECK If BILLING ADDRESS <br /> BUSINESS NAME / M,ay f� � P NE# 9�_ � �• <br /> HOME or MAILING ADDRESS �,_ I n _ , I „/) FAX# 1 <br /> CITY STATE ZIP J 1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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 applica on and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT an <br /> Ai M ATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 t0 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: RECEIVED <br /> COMMENTS: <br /> JUN 16 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> at <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY. EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: Q DATE: r „ u 4.7 9 <br /> Date Service Completed (if already completed): SERVICE CODE: UPI P/E: 2 <br /> Fee Amount: $ 16-2-60 <br /> Amount Paid 'sa _ Payment Date G <br /> Payment Type C Invoice# C l S' S1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod). <br /> REVISED 11/17/2003 <br />