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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# Exr, <br />SERVICE REQUEST # <br />� SR-�gCo �a <br />OWNER ERATOR,�� \ <br />CHECK if BILLING ADDRESS <br />FACILITY NAMCG ` 5 I <br />J <br />�5 t <br />S E Alp s <br />C� Street Number <br />W t L' <br />Dire.ti <br />W R -Y <br />StreetName <br />5 <br />C <br />ZI Cotle <br />HOME or MAILING ADDR (if Different from Site 'n.�11.+1ree�ss) <br />t l..©Wer SIC Number <br />EMPLOYEE #: <br />P <br />% D <br />Street Name <br />CITY <br />STIE�� <br />is—� ZIP <br />PHONE# � E�. <br />t <br />APN# <br />LAND USE APPLICATION# <br />PHONE # t, �/'r� �� <br />( V It <br />(� <br />EMPLOYEE#: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# Exr, <br />HOME or MAILING ADDRESS <br />FAx# <br />( ) <br />CITY STATE 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 ENVLRONMENTAL 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 applicatid thork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stands ds, S",U11FR11!4h'7s. <br />APPLICANT'S SIGNATURV: b DATE:/ <br />PROPERTY / BUSINESS OWNERIV OPE O / MANA9TR ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLIedNT is not the B/LLING PARTS 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. PAYWmT <br />TYPE OF SERVICE REQUESTED: <br />RECEIVEp <br />COMMENTS: <br />NOV 2 2 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: t <br />'22- 1 / 22 <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: it ZZ 1-' <br />Date Service Completed (If already co plated): <br />SERVICE CODE: <br />Fee Amount:5C9Amount <br />Paid <br />L � <br />Payment Date <br />h( 2-2-12"t,'? <br />Payment Type Invoice # <br />Check # <br />Received By'AW <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 PF- A <br />