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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �'SE VICE REQUEST# <br /> ► 0oS -7-� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> 42AM d-1 C W cc 9 d � <br /> FACILITY NAME I C 2 3 <br /> S2 / <br /> SITE ADDRESS <br /> ADDRESS C'6A f y C OU&I 7 S ?,!! C ly-7d,✓ <br /> O �3 C�et Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> fG Z 3 CAVA t Y C 7 Street Number Street Name <br /> CITY l STATE ZIP <br /> e-4 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (201 ) yrs J' S1 z C)1F -5 �a <br /> PHONE#2ExT. BOS DISTRICT LOCATION CODE <br /> c2�-� ) g Z�a 9 s z 3 s i L 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1 2-4 Ma C C d�,/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME „ J PHONE# <br /> ExT. <br /> -C � :• ��•'�'-�t LUt t L L�/lav� 0 6c.c �. L v ?vy y � S 8 S'� <br /> HOME or MAILING ADDRESS FAX# <br /> 91� 1 3 WIt.9 c 7 (701 ) 9S2 39 s'/ <br /> CITY S -Z0 f STATE C-0 ZIP c1 S l ?- <br /> BILLING <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 or <br /> 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 nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �P 1314a 'rL <br /> PROPERTY/BUSINESS OWNER OPE R/M 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 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. 1 <br /> TYPE OF SERVICE REQUESTED: VeY ; IC"�}0Dn o} sefbe;CkS ]� SE' }iL t�ol<ATM oih�o /Fccti �/pes <br /> COMMENTS: b,Jner -h V 79C0'Ir ep'OI i �p �S Of <br /> Sf'17f1C }Gry{I k G;nc, D p�,■q��t,�,� ' ::1 <br /> 6h I,nPs. <br /> N I CALL(209)953-7697 <br /> RECEIVED FOR INSPECTION. <br /> 48 HOUR NOTICE <br /> SEP 13 2022 REQUIRED. <br /> ACCEPTED BY: HEALTH <br /> EMPLOYEE#: ENVIRONMENTAL DATE: <br /> ASSIGNED TO: IC EMPLOYEE#: DATE: ! 1, a a <br /> Date Service Completed (if already completed): SERVICE CODE: C> P I E: q3 pa <br /> Fee Amount: $ $-�, Amount Paid S-(o Payment Date 1//3 Z 7— <br /> Payment <br /> Payment Type Go [Invoice# Check# Received By: <br /> EHD 48-02-025 Coa I 8� I Z t73 SIR'FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />