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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FROM 2382'-� S RCDO gC�859 <br /> OWNER I OPERATOR <br /> k�4 me, I I CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> tA b w mot iA i s e. -3- '.01 <br /> SITE ADRESS LOW L f �C'L�Yi W e h I CO Ct S -` L <br /> V Street Number erection (�(l Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7 / Street Number Street Name <br /> CITY { ,IN STATE C 14 ZIP C 212--I UCJ�t 4" J <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (adr� p 3 . <br /> PHONE#2 EXT. EMAIL BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ""�� <br /> ,Y„ y-I . f�_ 1( i" CHECK If BILLING ADDRESS <br /> BUSINESS NAME 46 mLoCX6Ii( 64, <br /> 1�� '�1 '^ ��1 P ONE# O,^ n EXT• <br /> t'! l ' <br /> HOME or MAILING RESS ` FAX# <br /> STATEZIP O v 1 EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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 RAL laws. <br /> APPLICANT'S SIGNATURE: I DATE: 6 I9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is 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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it Is provided to me or my <br /> representative. VT MENT <br /> TYPE OF SERVICE REQUESTED: Fuocl <br /> REGEIVED <br /> COMMENTS: �� G� Q(,�j(�I'S<`u� <br /> JUS [ 0 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: e. EMPLOYEE#: DATE: 6/20/23 <br /> ASSIGNED TO: EMPLOYEE#:q g2rj DATE: G 12(r,k'2- <br /> Date <br /> 2Date Service Completed (if already Completed): SERVICE CODE: P I E:k(002- <br /> Fee <br /> 2Fee Amount: 5 kS(o,O(D Amount Paid �s'� Payment Date Z <br /> 257 <br /> Payment Type G Invoice# C�I Set!C# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />