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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E - J a 003.0aU� <br /> OWNER/OPERATOR <br /> it CHECK If BILLING ADDRESS <br /> FADILRY AME � ' <br /> p,,4\YY Z L\ Y\42 <br /> SITE ADDRESS Gtn,.c7yi 1 /�l�1 q 5 a(,'O <br /> Sree[Number Direr ion Street Name I C/ Cit ZI Code <br /> H1OOMM,tEGor(( ` <br /> MAILING ADDRESS (If Different from Site-Address) <br /> l"`s— t n NL,::) Street Number Street Name <br /> CRY STATE ZIP <br /> }cn C o <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> (I'M g3� �aHa <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> C u� ✓rno Nkat'-)rw,2 Z <br /> BUSINESS NAME d HONE# E.' <br /> �n�l a - IRN <br /> HO E or MAILING ADDRESS FAx# <br /> ( I <br /> CITY STATE C75 ZIP <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 /> 4&KICANTISSIGNATURE: <br /> l///�1f_O`I1' DAU: / 2 <br /> PROPERTY/BUSINESS OWNER //OPERATOR//MANAGER ❑ OTHER AUTI1ORIzFD AGENT❑ <br /> If APPLICANT is not the BILLING PART}' 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 t0 Che SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available anple t6g�.�1!),IC it is <br /> provided to me or my representative. " ^� ���Cry 1 <br /> in <br /> TYPE OF SERVICE REQUESTED: MW Yll <br /> COMMENTS: C 7 2022 <br /> D1 �VV(/YJ SANJOAQUINCOUNTY <br /> 1 U ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: —1^J, <br /> AsSIGNEDTO: z3n/ EMPLOYEE#: DATE: <br /> DWI <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 1� <br /> Fee Amount: it ' Amount Paid SCS D D Payment Date 7 Z2— <br /> Payment Type ` Invoice# Check# Received By: <br /> EHD 48-02-025 // n SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (,fJ1( lS�`-su13S n,0 5 JUW`+ <br />