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SAN JOAQU COUNTY ENVIRONMENTAL$SALT,�EPARTMENT <br /> U6 SERVICE REQUEST ' 1, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DoNLtiA a, ncrwrt Go II I 4 SZV6 '271 <br /> OWNER OPERATOR >et CHECK If BILLING ADDRESS <br /> A <br /> ❑ <br /> FACILITY NAME IrGU r� <br /> SITE ADDRESS \ 16, 4 `6treel <br /> Nam¢ (9 <br /> Street Numb¢r Olrecllon it ZI Code <br /> HOMEor MAILING ADDRESS (If Different from Site Address) 2(o G <br /> SeeN Number <br /> Sr 1 Na e <br /> CITY STAT 4 ZIP <br /> PHONE#1 Ems• APN# LAND USE APPLICATION# <br /> O 1 <br /> PHONE#2 EeT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> HOME Or MAJUNG ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: t, 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 th.:,farm <br /> I also certify that I have prepared this application and that the vecmk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. eY <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWN OPERATOR/MANAGER ❑ OTNER AUTHORIZED AGE\T❑ GC C--3 <br /> LJAPPLfCANrisnotrhe BiLLINGPat.rr proofofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> aboae site address, hereby authorize the release of any and all results, geotechnical data and/or environmemalisite assessment <br /> information to the SAN JOAQUIN COUNTY ENVtRONMENTAI-HEA1111 DEPARTMENT 2S soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N <br /> COMMENTS: ueQl- �. ��CEI V`D <br /> SEP 12 2022 <br /> SAN QAQUIN <br /> ACCEPTED BY: EMPLOYEE#: EPAN TAL <br /> ASSIGNED TO: ,^ DATE: <br /> EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: Ou <br /> P)E '\ <br /> Fee Amount: i Amount Paid Payment Date Gl I2 Z'1 <br /> Payment Type Invoicem. <br /> ' # Cp # Received By; <br /> EHD 48-02-025 ( �-'T ci 7� 29 1 ( 'S o SR FORM(Golden Rodd- <br /> REVISED 11/17/1003 1 <br />