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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �- o +-rocv-- FA00Q & 6 -�V SROV9 (oQ4-1 <br /> OJMNER OPERATOR 1 <br /> d <] YY l I L CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> o vt C I G15 � OCa 45 <br /> SITE ADDRESS 1 7 C Union <br /> S} SI OCY i-t:r t 15.o O& <br /> �[reet Number DlraJmion Street Name Cit 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ?;Ito e: Street Number Street Name <br /> CITY STATE ZIP <br /> 10 c-%:-cn 95 AO <br /> PHONE#t Ex. APN# LAND USE APPLICATION# <br /> 12091 I el 4 9-)9 s <br /> PHONE#2 Ext• BOB DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <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 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 FED laws. <br /> APPLICANT'S SIGNATURE: j�w DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PART yproof ofauthorization tosign isrequired 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 environmential/vsitpe�,aasssseepsssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and RMV,I71�rTl�i it iS <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AN 12 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: KL <br /> EMPLOYEE#: G 5 Q DATE: 1-19-23 <br /> ASSIGNED TO: K L EMPLOYEE#: +599 DATE: l I — t a •-a 3 <br /> Date Service Completed (if already completed): SERVICE CODE: d CO I PIE: '� O <br /> Fee Amount: 15 Amount Paid �r/ _ Payment Date �y '1-V Z <br /> 31 <br /> Payment Type V (C,A Invoice# eck# g LT-p Received By:Aa r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003. / <br />