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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or r erty tt-- FACILITY ID# SERVICE REQUEST# <br /> �qS S lG� C'dhV N:f Sly ��00215 Cl S � <br /> OWNER/OPERATOR ( ,) CHECK If BILLING ADDRESS <br /> FACILITY NAME CAev�sn <br /> SITE ADDRFySS,^A„�h S� N //titai� <br /> �nll YY44 StreettNNumber Direction SVee[Name C ZI Code <br /> HOME or MAILING ADDRESS (If Different from SiteAddress)Address) <br /> 3 rl/ C / Street Number Street Name <br /> CITY '�F • /" d l STATE CA ZIP tl,ry� <br /> PHONE#1EXT'_CAD APN# LAND USE APPLICATION# Tom/b <br /> Gle I Lf0� — ; <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ / /e ( �+� /� <br /> CHECK If BILLING AD0RES5O <br /> BUSINESS NAME �. (� PHONE# EXT. <br /> HOME or MAILING ADDRESS -31/7 91 0-wrn FA%# <br /> CITY J Q .O STATE CA ZIP 9 q g 4 <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 ENvtRONMENTAL 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. (7 <br /> APPLICANT'S SIGNATURE: DATE: / f� 2O Z 2— <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHOm7ED AGENT❑ <br /> 1JAPPLICANT 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 Ole 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. r <br /> TYPE OF SERVICE REQUESTED: '(A/ 0 WAW Cants f ` <br /> COMMENTS: <br /> JUL 13 2022 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �vn ' � EMPLOYEE#: DATE: -'-"7]�,z] <br /> ASSIGNED TO: • I/L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 04P/ P 1 E: / OZ <br /> Fee Amount: /S Amount Paid -,� ` _ Payment Date -:qji 2,,l [2 L <br /> Payment Type l Invoice# Check# p�� r Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S <br />