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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> I lay to a <br /> FACILITY NAME Q)( ^ A \ X"��( 7wuG'l <br /> SITE ADDRESS 7 q(-0 TUJv� t rA I f l�� <br /> L.U Street NumberDirection Street Name CI Zip Code <br /> HOm�iMAILING ADDRESS (If Different tfrrom�Site Address) <br /> t7 V l I;k- - Street Number Street Name <br /> CITY � kDv` STAT§,- ZIP �`5 <br /> PHONE#1 'I U En. APN# LAND USE APPLICATION# <br /> (zoo ) -41 - 5 94 1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mctlztn ,�50kekG tT <br /> CHECK If BILLING ADORES <br /> lU tl\A <br /> BUSINESS NAMEExr. <br /> Xt dncA � OOH Y�/CK 5G - ly 6 <br /> HOME or MAILING ADDRESS I�� S;1/1.1_ FAx# ) <br /> CITY �;�OQ6A .. _ t ]LTA STATE /t e... ZIP /'aM <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 Cakes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: M CT S C � 1 -&012.?- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IrAPPLICANT is not the BILLING PAR 7'Y 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 an0 t��e it Is <br /> provided to me or my representative. ,, II^^\k V y�(1,� A <br /> TYPE OF SERVICE REQUESTED: T�A U <br /> COMMENTS: JUL 2 0 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Ole PIE: I G <br /> Fee Amount:rly Amount Paid /S-� Payment Date 'Zto 2,v Z <br /> Payment Type9 Invoice# Check# Received By: Wfl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />