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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business`` or Pr perty <br />C�IQV-\ <br />FACILITY ID # <br />/,,SERVICE REQUESTII# <br />�cogs Q 1 <br />OWNER / OPERATOR <br />1 KI� C s� a ,/ <br />C `C Y <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DDR S \\ <br />SITE ADDRESS <br />street Number <br />Direction <br />Cl <br />Street Name <br />w n <br />CVI\t r <br />Gj S l <br />f ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ex -r. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />173 <br />LOCATION C O E <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/� <br />1�k` ^1�� � �� 1 CHECK If BILLING ADDRE <br />v <br />BUSINESS NAME <br />COMMENTS: ^y4Ck <br />P # EXT. <br />M) ? — <br />HOME or MAILING <br />DDR S \\ <br />FAX# <br />CITY yk� <br />STATE ZIP I? S Z 3 <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 wor to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd FEDERAL <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNE OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLIC. Tis 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 ygW$ffentative. <br />TYPE OFSEI'tGDVef � 6zlrInFC ki- 46T re'.4 J/ DL',�e <br />to ge <br />L S YI <br />COMMENTS: ^y4Ck <br />(iro-'- �`� �i V-)".Iol vV� <br />AUG 17 2022 ' <br />CALL(209)953-7697 <br />SAN JOAQUIN COUNTY <br />FOR INSPECTION. <br />ENVIRONMENTAL <br />48 HOUR NOTICE <br />HEALTH DEPARTMENT <br />REQUIRED. <br />ACCEPTED BY: r �G - <br />EMPLOYEE M <br />DATE: 9/n aR <br />ASSIGNED TO: T1s <br />EMPLOYEE #: <br />DATE: i/I f a <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />O� <br />P /E: <br />Fee Amount: <br />Amount Pai <br />5/_i OZ) <br />Payment Date <br />�Z <br />Payment Type <br />Invoice # <br />Check # 1 t b $ <br />IP42 <br />I iieceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />