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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />usiness or Prope <br />�//� I ' CHECK 1f BILLING ADDRESs0 <br />FACILITY ID # <br />SERVICE REQUEST # <br />C� <br />PHONE# E*• <br />HOMEor MAILINGADDRESS <br />SR00g5898 <br />PERAT (�tom,\- <br />STATE Z1P / / <br />�I t UME r Y ttll �� ���u <br />OCT 13 2022 <br />*ERA <br />- - SS ca _ G C� _ _- %� l/ell / 2 <br />' <br />i/1l ' "� ,l c" SCa C A— <br />SttBONumber DlrectlonStregt NameCode <br />ILING ADDRESS (If Different from Site Address) <br />HEALTH DEPARTMENT <br />2f ?Street <br />/ /; �� 5G U <br />Number <br />DATE:/0'�I !L2- <br />ASSIGNED TO: <br />t �( L�� ��(vAEx4 <br />$TATE ZIP <br />EMPLOYEE#: <br />DATE: li7 - <br />LAND USE APPLICATIONJVf1 <br />—/Tr.APN# <br />SERVICE CODE: <br />PHONE#2T <br />ES, <br />C4 -2 -- <br />(S) X42-- 2 0 c�V� <br />Fee Amount: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR '�/� � <br />�//� I ' CHECK 1f BILLING ADDRESs0 <br />BUSINESS NAME <br />–)--� <br />VU <br />PHONE# E*• <br />HOMEor MAILINGADDRESS <br />FAX# <br />Cttt <br />STATE Z1P / / <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized anent 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 tome or my business as identified on this form <br />I also certify that I have prepared this a is * n that tjie work to be performed will be done in accordance with all SAN JOAQuDN <br />COUNTY Ordinance Codes, Standa , ST d laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNS P RATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLINGPARTP 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 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: <br />IA—) <br />_,U ✓i,A.l +' <br />PAYMENT <br />,COMMENTS: <br />OCT 13 2022 <br />' <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />_.ACCEPTED BY: <br />/ /; �� 5G U <br />EMPLOYEEM <br />DATE:/0'�I !L2- <br />ASSIGNED TO: <br />yL <br />rL ,^-J S <br />EMPLOYEE#: <br />DATE: li7 - <br />DateServiceCompleted <br />(if already completed): <br />SERVICE CODE: <br />PIE: /& L <br />Fee Amount: <br />Amount Paid <br />Pa/ment Date <br />Payment Type <br />�/ C <br />Invoice # <br />CheEk # `S 0 'T /D tyG <br />Received By: <br />EHD 48-02-025 / ° 1 Z ( Z SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />