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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .'A 031-52-9 1 3� lop l-o <br /> OWNER/OPERATOR <br /> ^ I � CHECK If BILLING ADDRESS <br /> " <br /> FACILITY NAME ' SHOP <br /> l <br /> SITE ADDRESS 6'c)y S , C E tJT K A L )Av F p I/ q 5�kJo <br /> Street Number Direction I Street Name City Zip Code <br /> HOME Or pMAILING ADDRESS (If Different from Site Address) Ch�, L-� y <br /> (1-332-3 D • Street Number Street Nam <br /> CITY STATE ZIP <br /> S"f�C (Z►gym I�`7e� C /a `� 5 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (r�I ) 0C�5 r- OoR <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME K I PHQNE# ExT. <br /> TE CT2 vr' 0 (-6,I <br /> HOME or MAILING ADDRESS FAX# <br /> CITY n V 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. qq y <br /> APPLICANT'S SIGNATURE: �c (�L.`1 �. -<< rl ��=�, l i ( DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ C �. C) <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 inforr,�J i n to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it Is provided_TO �� <br /> representative. R <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � <br /> 0�.. q� � �� � ���, 20✓lG1 Y1G�{ I /J V uc Y� SAN JOAQ(/I <br /> U_ H N p�PgR rAL <br /> EN <br /> ACCEPTED BY: EMPLOYEE#: DATI �J �J <br /> ASSIGNED TO: EMPLOYEE#: DATE: // v <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: v 2 <br /> Fee Amount: I , - Amount Pai /6�,�� Payment Date � 2- <br /> Payment Type t Invoice# Check# j(o"7�ggj Recei ed By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />