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r <br />i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business orProperty <br />�f o C-6KY R67 TA -i L JToC:1 <br />FACILITY ID # <br />SERVICE REQUEST # <br />5R0OS5VO3 <br />OWNER I OPERATOR <br />0 H( -T /1 �' (-A <br />MO (��T Ait I <br />CHECK It BILLING ADDRESS <br />FACILITY NAME <br />(,PHONtl ).7822 632 E"` <br />SITE ADDRESS <br />D Street Number <br />DiElan <br />Street Name <br />(AX # ) <br />CI <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 2 Lr/ <br />Street Number <br />O / L e r <br />I /� J / Street Name <br />CITYS Aa oL / U l / <br />I �✓ <br />/ S�T_ATE ZIP 11 � <br />6A-STATE <br />1AND <br />PHONE#t Ev. <br />IS/v 1780 0325 <br />APN # <br />USE APPLICATION # <br />PHONE #2 Ez . <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />R.EQUESTOR M"l 1 <br />� <br />' V <br />u' V� <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 6. 05A -I'5 <br />U/ <br />Sur°��,�n,y�/ / <br />/�`A <br />(,PHONtl ).7822 632 E"` <br />HOME Or MAILING ADDRESSq, J <br />I <br />Iv,�//� <br />�/ <br />( <br />(AX # ) <br />CITY f i O l� / ON <br />STATE 64- ZIP 'I <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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: /j1'L4j,J� DATE: <br />PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />If APPLICANT is not the BILLING PARTY proof Of authorization to Sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of thettiASePlelpN(elt the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmcntaUs @ ent <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available 48pl1q ypttl rae It Is <br />provided to me or my representative. _ G UU LL 2 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />F117-1 4-7206972% /26 7-/!-/L r1-0,eC- <br />COUNTY <br />ACCEPTED BY: EMPLOYEE #: DATE: 2-0 ZZ <br />ASSIGNED TO: I A. �. EMPLOYEE #: DATE: -0/ <br />Z <br />Date Service Completed (if already completed): SERVICE CODE: f P / E: <br />Fee Amount: Amount Paid 6 8 Payment Date ?12-19/22 <br />Payment Type GA e Invoice # Check # 131`1 Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />