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kils-� e2 asp X80 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> Zrnar 1,n-k/ py,Ire,s nc - <br /> FACILITY NAME <br /> Del fro G,'a Y,,-- �1 <br /> SITE ADDRESS � or fs.Yl <br /> 1 &,66 ? Stmat Number Direction / Slreet Nemo cit Co a <br /> HOME Or MAILING ADDRESS (If Diff ent from Slts Address) h �/ <br /> Ay -?rU � . �� a�� Sirae[Numbar �' � ma ^ <br /> CITY^ fro $TATE ZIP <br /> PHONE#1 rte — a E APN# CL ANDD USE APPLICATION# <br /> 559 y <br /> PHONE#2 3 D Z — 92 3 r ' BOS DISTRICT LOCATION CODE <br /> (SS7 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINEss NAME PHONE# Ev' <br /> HOME Of MAILING ADDRESS FAX# <br /> I ( ) <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> 1 acknowledge that ail site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> ior activity will be billed to me or my business entl I d on this form. <br /> I also certify that I have prepared this pplication and that 63pw r e perforn d will be done in accordance with all SAN JOAQUIN <br /> 1 COUNTY Ordinance Codes,Standar ,SDs. <br /> APPLTCGUR• <br /> DATE: 16 <br /> PROPERTY/BUSINESS OWNER <br /> OPERATOR/ TANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is ,t the BILL,NGI4RTY proof of authorization to sign is required Title <br /> 1 U TI N SE 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 /> s provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C h a n J�'„ d O W n" S P <br /> COMMENTS: ECEI ED <br /> 3l/4� 2oZZ S }arG eh ,n� oL alVneicJ,,'�a OCT 13 <br /> 2022 <br /> i <br /> SANJOAOMN aNiY <br /> ELTHDNEM AL HEgLTH EPA MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: t �fe EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: 1 �� <br /> Fee Amount: 1 S v Amount Paid �� Payment Date I 1 b 1i <br /> Payment Type Invoice# C 9CR# I S�37j S (� Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />