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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> 0 SRO Gb NS 26 SROS(vViV <br /> OWNER I OPERATOR _ <br /> MA f� ' ELLEN E- I�� CHECK if BILLING ADDRESS <br /> FACILITY NAME �y/q�(I'}`L/�1� -TUDIC - [� fL1 J(-, f /h/�I'r-T j r� <br /> SITE ADDRESS MOW 0-A-Z19 JWI��i C7 LV�LI VND � L�� <br /> Sfraet Number Direction T� Street Name City <br /> ZI Code <br /> HOME or MAILING 1ADDRESS <br /> Iv(If Diff <br /> IfDifferent from Site Address) L ul nJz? nvT' TJUC <br /> ` 5 LuC % P-3L &yC Street Number Street Name <br /> CrtvS IP 40 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ) a (o -q3L <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <br /> BHAJNG 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,STATE and FEDER laws. <br /> APPLICANT'S SIGNATURE: n ���Q �t� DATE: D—2162 1 a 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 12i l OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof ofauthorization t0 sign is required 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: l �VI�Q ```ZE U r I PAY <br /> Kr r- <br /> COMMENTS: <br /> FEB 16 2023 <br /> &aN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME14T <br /> ACCEPTED BY: GA1.1 't EMPLOYEE M O DATE:2/At 2,5 <br /> ASSIGNED TO: n In tl yA C I EMPLOYEE M 2� DATE:2 111 2 3 <br /> Date Service Completed (if already completed): SERVICE CODE: l/n- ' PI E: V Z <br /> Fee Amount: Amount Paid ,��S Payment Date <br /> Payment Type Invoice# I#Ps, 3a Received By:"/f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> +PSS�131q <br />