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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> + OWNER 1 OPERATE i <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> t r"30 Rio calcAb <br /> SITE ADDRESS <br /> Street Number Direction St RVA Cit Zi Code <br /> HOME or MAILING ADDRESS (1f Different from Site Address) <br /> 4 G" +�—��7�� �' Street Number Street Name <br /> CITY STATE ZIP <br /> �' s <br /> PHONE M ExT• APN 4 LAND USE APPLICATION# <br /> PHONE#2 D Exr, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST OR j lC�C� J <br /> CHECK IfBILIINGADDRESS <br /> ❑ <br /> BUSINESS NAME PHONE#5jo ,5 Q S�-zyr� E <br /> HOME or WAILING ADDRESS FAX# U <br /> CITY --rl% ( 6, STATE zip <br /> ''TTS\ ll <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTii 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 RAL laws, <br /> % APPLICANT'S SIGNATURE: 4 V Av DATE: <br /> PROPERTY 1 BUSINESS OWNER[] T�RA'roR/MANAGER ❑ OTHER AIITHORIZEII AGEN ❑ <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at lite <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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. ,4Y <br /> TYPE OF SERVICE REQUESTED: L.� 'FlYTID <br /> COMMENTS: <br /> UL 2 6 2022 <br /> ENVIRON <br /> V1RONlN COUNTY <br /> HATH DE ARTM�NT <br /> ACCEPTED BY: n EMPLOYEE#: p DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: f DATE: ry �2 <br /> Date Service Completed (if already completed): SERVICE CODE: �( n P ILE; <br /> Fee Amount: f � Amount Paid j , Payment Date -q- 2�I ZZ. <br /> Payment Type L c Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />