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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Type of Business or Propegy <br />shav`e- <br />OWNER / PERAT <br />�ti �L1 <br />FACILITY NAME <br />SITE ADDRESS <br />SERVICE REQUEST <br />FACILITY ID # <br />SERVICE REQUEST # <br />SR00g5Sg8 <br />CHECK If <br />CA - <br />.,.,.e ,.e� <br />If Different from Site Address) <br />cl D CodePPHONE#2 <br />Number <br />.{nom��(C/Street <br />V,eat Name <br />tADDRESS <br />STATE zip <br />,Jtrz <br />C --H - <br />OCT 13 2022 <br />ppN # <br />LAND USE APPLICATION # <br />--EUT• 7 <br />HEALM DBPARTMEN I <br />BQ$DISTRICT <br />LOCATIONCODE <br />REQUESTOR <br />BUSINESS NAME I I <br />HOME Or MAILING ADDREE <br />D <br />CITY <br />CONTRACTOR / SERVICE REOUESTOR <br />u rn -e,S <br />CHECK If BILLING ADDRESS 0 <br />FAX # <br />STATE zip <br />7 <br />i <br />3 <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 a is ' n a that e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Coder, Standa s, ST dd FEE laws. <br />APPLICANT'S SIGNATURE: <br />� <br />( DATE; <br />PROPERTY / BUSINESS ONVTI i' � TOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLIC /T is not the BILLINGPARTY 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 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. <br />TYPE OF SERVICE REQUESTED: i 1 1 LJ y jb\ <br />,. l '+ <br />PAYMENT <br />REGEIV <br />COMMENTS: <br />1-1 <br />OCT 13 2022 <br />SAN lDApulN cOUN1Y <br />EkVIIiDNIIIN'AL <br />HEALM DBPARTMEN I <br />ACCEPTED BY: <br />C C <br />EMPLOYEE#: <br />DATE: <br />l0 ZZ <br />/o <br />ASSIGNED TO: yl LA /� S <br />EMPLOYEE M <br />DATE: L <br />Date Service Completed (If already Completed): <br />SERVICE CODE: <br />P i E: / �G .� <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />v 13 %17 <br />Payment Type G,S <br />Invoice # <br />C4e6k # /S C IT/D L�.. d / 1 <br />Received By: <br />EHD 48-02-025 <br />l °( t( �' Z SR FORM (Golden Rod) <br />REVISED 11I17/2003 � V 6 <br />A�/ �L <br />