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IL <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST � <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# ExT. <br />FACILITY ID # <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />NOV 3 Q 2022 <br />SAN JOAQUIN COUNT) <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SIQ (blD 10 L� <br />OWNER/ OPERATOR <br />�05� L�e�Ano Ortarte/a <br />CHECK If BILLING ADDRESS ❑ <br />k}err,Gn�� <br />FACILITY NAME�1�� <br />/ <br />C.+S' <br />DATE: it 3(C>[,7 <br />ASSIGNEDTO: <br />SITE ADDRESS —��WU <br />EMPLOYEE#: <br />e/M, r0.1C <br />J'E'QCI��'oY� <br />Date Service Compfeted (If already Completed): <br />'p <br />�IS20 J <br />Street Number <br />Dlrectlon <br />Street Name <br />Cit <br />Zi Code <br />NOME Or MAILING ADDRES (If Different from Site Address) <br />Payment Date 113U Zv L7— <br />Payment Type <br />3111 <br />Street Number <br />Street Name <br />SS <br />CITY <br />n "MNO <br />STATE ZIP <br />PHONE #t <br />E"T <br />APN # <br />LAND USE APPLICATION # <br />(qi6) 5yt -"173 <br />PHONE #2 <br />1 4,(Yl ) t - "I4 sti <br />Ez . <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING AGGRESS <br />BUSINESS NAME <br />PHONE# ExT. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY STATE ZIP <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 <br />or activity will be billed to me or my business as identified on tWs form. <br />I also certify that I have prepared this applicati and that e ydyJk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATEE E !� 1 <br />APPLICANT'S SIGNATUr�R(E: DATE: i L 13 a 22 <br />PROPERTY/ BUSINESS OWNER dll� OPERATOR/1 ANAGER ❑ OTHER AUTHORIZED AGENT <br />IJAPPLICANT 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 <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. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />RECEIVED <br />COMMENTS; <br />t, / J , _ �l— <br />1 <br />NOV 3 Q 2022 <br />SAN JOAQUIN COUNT) <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />zi Z <br />i <br />DATE: it 3(C>[,7 <br />ASSIGNEDTO: <br />( <br />EMPLOYEE#: <br />DATE: II O ZZ <br />Date Service Compfeted (If already Completed): <br />SERVICE CODE: <br />573 <br />IP/E; i J <br />Fee Amount: <br />Amount Paid <br />S_ <br />Payment Date 113U Zv L7— <br />Payment Type <br />Invoice # <br />Qwc& #'S <br />SS <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />