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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />t�^f�'� <br />-5(G4CA <br />ERVICE REQUEST # <br />CO Sha �cQr��. oY,l ) <br />CO/✓S (,VVAJ <br />IDSI2 <br />Wgq�+S 2— <br />OWNER/ OPERATOR <br />OWNER/ <br />FAX # <br />�IGILt, OV�ii C�.1. �5 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />CITY <br />tV- f /1 <br />SITE ADDRESS <br />L{60 E <br />L'1� <br />i`LT"'TI CStraetN <br />L �'��p1,' <br />k.`t.4. J'Z Street Number <br />DlrDeetion <br />ma <br />Cityri <br />Zip ode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHOLN,E� #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />060, ) <br />PHONE#2 EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/�w/��ADv�� p� O� I CHECK If BILLING ADDRESS <br />t�^f�'� <br />-5(G4CA <br />` �V Jr/� <br />BUSINESS NAME <br />CO/✓S (,VVAJ <br />PHONE# EXT. <br />ti - 0 ? <br />HOME or MAILING A DRESS <br />`6t,Sd <br />FAX # <br />WA-�) O <br />( , <br />CITY <br />STATE ZIP <br />BILLING ACKNOWLEDGE NT: 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 FEDEP41, laws. <br />APPLICANT'S SIGNATURE: 4 cZ DATE: I I N I <br />PROPERTY/ BUSINESS OWNERL{! OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is 1101 the BLLLLNG 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 and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ��(� 7 L�y''V t/Vl.f:fJ� <br />COMMENTS: <br />JAN 14 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTHDEPARTMENT <br />ACCEPTED BY: EMPLOYEE M DATE: <br />ASSIGNED TO: EMPLOYEE M DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Z P / E: Q <br />Fee Amount: 01 Amount Paid S — Payment Date <br />Payment Type Invoice # Check # l u Z Received By: ' <br />EHD 48-02-025 sq -1,7 <br />, 1 SR FORM (Golden Rodj <br />REVISED 11/17/2003sq <br />. nt0 A —1 7 I <br />