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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME �� / <br />�jRDp �� � F - zEM' <br />y,,C (� <br />FACILITY ID #RVICE <br />U0E2mI3�-115�: <br />REQUEST # <br />19102 01 <br />OWNER / OPERATOR <br />Nr cr— ( t" �/ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ,� �� S • U •-•� <br />I ASCO <br />ASSIGNED TO: OA <br />EMPLOYEE #: <br />DATE: <br />SITE AD RE 7 Z <br />Street Number <br />Direction <br />(� N Or <br />Street Name <br />/ <br />5 )ex � <br />City <br />Zio Code <br />HOME or MAILINGADDRESS (If Different from Site Address) <br />t_ L(t 1 / <br />( ✓ r� �V� Street Number <br />to <br />Str¢et Name <br />CITYSTATE <br />c>c, <br />611- <br />ZIP <br />Receiv d By: <br />PHONE#i pE"T• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 Ems• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQUESTOR 9 `�f CHECK If BILLING ADDRESS <br />UGv" l� <br />BUSINESS NAME �� / <br />�jRDp �� � F - zEM' <br />y,,C (� <br />HOME Or MAILING ADDRESS <br />FAx# <br />CITY 7 G /C / v_� STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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, ST TE D S. <br />APPLICANT'S SIGNATURE: �/� DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ 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 pr o� jj�y�located at the <br />above site address, hereby authorize the release of any and all results, geotechtlical data and/or environmr�itAl ,I ent <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an dl SE ! jJ,QT� t is <br />provided to me or my representative. v61 YC <br />TYPE OF SERVICE REQUESTED: V`t,N( I �S <br />3 0 2022 <br />COMMENTS: <br />ENVIRONJOAQUIN COON <br />HEALTH <br />HEALTEP <br />ACCEPTED BY: Y M <br />EMPLOYEE#: <br />DATE. I 0 21 <br />ASSIGNED TO: OA <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: U <br />Fee Amount: IS <br />Amount Pal <br />to <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # /� g % q� 7 <br />Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />