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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />EAU) zt ick-ci <br />SERVICE REQUEST # <br />S9--M8(0-9C 3 <br />OWNER / OPERATOR CHECK if BILLING ADDRESS acksein masoeerj <br />FACILITY NAME A „ Y- AI\ -c ev\ot< e 5 \r‘a ? 0. \-\,)- :,_-.\••,-oce t ‘1 <br />(1,07_7-k1-64' treet Number Direction <br />SITE ADDRESS 6>ca 0* •-t 05e ix\k )4.e_ c <br />Street Name <br />t.kk-kcJY\ <br />City <br />(4S (293 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />Pnorig #1 EXT. <br />2M) s&—vi4-1 <br />APN # LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/01/4.6\ 5—C - \CNN \X-5 CN ea) CHECK if BILLING ADDRESS <br />BUSINESS NAME A .,, ,s(---N\ 6 1,1\001, 3\t‘P-R 9-- e3k <br />I <br />1 <br />PHONE # <br />(If\ ) <br />Err. <br />HOME or MAILING ADDRESS <br />c\c, 2_ Q \ t 6.,S(Kc c.5 )):--) 3 <br />Fax # <br />( ) <br />Crry 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 />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, Stan , STATE and FEDERAL laws. • <br />APPLICANT'S SIGNATURE: C; S_ty•C\ DATE: AVANI I 2/1 /9 )2 <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 prpAefk ,„my <br />representative. <br />r(CloltIVLD <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: MAY 24 2023 <br />1 cht S L,i 1---1-4) -h._ SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED By: "bmascrkire EMPLOYEE #: et 8(0s- e--- S <br />ASSIGNED TO: LiacA j.wr EMPLOYEE #: ot8i8 <br />DATE: '5( 2 y..., <br />DATE: <br />Date Service Completed (if already completed): SERVICE CODE: (1X2 k 1E: <br />Amount Paid Payment Date .6 713417D2: 2, Fee Amount1/5-G . 0® / slios„ <br />Payment Type c.75 L. Invoice # Check # Received By: /.1,-----/ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23