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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />GlI /7 <br />FACILITY ID # <br />P NE #) [� / =% s'• <br />baa <br />SERVICE EQU ST # <br />SQ (0 5 Z., <br />OWNER OPERATOR f <br />` <br />41 ^` w^ 7I - <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME I via, <br />` C.�V` � i <br />SAN JOAQUIN COUNTY <br />SITE ADORE,�S , I l �, / <br />Street Num r <br />Direction <br />/; <br />K r <br />Slreet Name <br />/ , (GSI GC <br />Cit <br />ZI Cotle <br />HOM or MAILING ADDRESS If Different fr m Site Ads) <br />23 DLJ l Street Number <br />DATE: (z �– <br />Street Name <br />CITY ���,,,, - TAT ZIP <br />' (4 ` <br />Ex , <br />PpNV! y�_0 _;Z( <br />APN # <br />LAND USE APPLICATION # <br />V -70 ,9 t„3, k- <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />` (/ CA l CHECK If BILLING ADDRESS <br />BUSINESS NAME /' /� ([- CV <br />P NE #) [� / =% s'• <br />baa <br />HOME or MAILING ADDR SS <br />FAX# <br />CITY 7J, . ' ATE ` LP <br />BILLING ACKNOWLEDGEMENT: , the undersigned propew or bu ness owne , 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 apis ion and that the ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S E and FEDE " L IfVS. <br />APPLICANT'S SIGNATURE DATE: � / C <br />PROPERTY / BUSINESS OWNER❑ OFOZIOR /MANAGER ❑ OTHER AUTHORIZED AGENT [3 <br />IJAPPLICANTis not the BILLING PARTY 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 />PAYMENT <br />COMMENTS: ' <br />RECEIVED <br />DEC 19 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY: <br />�r <br />EMPLOYEE#: 7C *� DATE: _ _ <br />(/ <br />ASSIGNED TO: nl t <br />EMPLOYEE #: <br />DATE: (z �– <br />Date Service Comple d (if already completed): <br />SERVICE CODE: V III <br />E: D <br />Fee Amount: l <br />Amount Paid <br />' <br />I Payment Date ( [ V ),t7 Z Z. <br />Payment Type C Invoice # <br />. Wk #1- <br />Received By: .44W 1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />2— <br />`2 <br />