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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST pP t�S 1 315 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ve-s iLroot FA 0013 357 SROOS75 3 d <br /> OWNER/OPERATOR <br /> Alma b/t 9 a rbn g- Diaz <br /> az L-LAI S /� - �i 4� FeW('1 CHECK If BILLING ADDRESS <br /> FACILITY NAME a 1/1 / � 1 <br /> SITE ADDRESSI A I.6, <br /> Street Number I Direction ' - ` 'i n-C r Street Name city Zip Code <br /> C <br /> HOME or <br /> /� <br /> or�'MAILING ADDRESS�(If Different from Site Address)LTL , V� � ntA. Street Number Street Name <br /> C STATE ZIP <br /> t'nQrxi"I C ((M12 CA <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (20) q <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( -34Le- OP) M arms C o q' <br /> CONTRACTOR / SERVICER UESTOR <br /> REQUESTOR <br /> m U M(Arb h-cZ Di a2 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PIN <br /> EXT. <br /> coy) al V1 ao-rapt. ( �� <br /> HOM r MAILING ADDRESS FAX# <br /> a M ns' e-t lz> ( ) <br /> CITY STATE ZIP 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 FEDERAL laws. I <br /> +16 APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERFRI MANAGER ❑ OTHER AUTHORIZED AGENT [3If APPLICANT is not the BILLINRTY, 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 IspAV d to me Or my <br /> representative. II�� AAkF <br /> TYPE OF SERVICE REQUESTED: ©W r h' INFO <br /> COMMENTS: <br /> SM JOAQU 4 zo?3 <br /> N4T 1)EPgRT NTM <br /> T <br /> ACCEPTED BY: j.�a I I n EMPLOYEE#: L�g /„ DATE: I Q_ (4-23 <br /> 4_23 <br /> ASSIGNED TO: /� . F-,M ul V-0 EMPLOYEE#: Q� QY DATE: f 'a_ 14 - ,13 d _ �1 3 <br /> Date Service Completed (if already completed): SERVICE CODE: ��� / PIE: <br /> Fee Amount: i(�a �/ Amount Pai /6;.� Payment Date / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 C <br />