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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPE , <br /> r <br /> t7 <br /> TOR C ` G CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS \ ry <br /> 2 t S ItTI"ulber Direction Street Name Cit Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En• PN# LAND USE APPLICATION# <br /> (2o Q) Q 113 - 3 9 6 A <br /> PHONE#2 Ezr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> O l.1 N CHECK If BILLING ADDRESS <br /> v l <br /> Bust SS NA r O t ` ' PHONE# EM <br /> HOME O'IILIN ADDRESS d V FA%# <br /> 2 1r c ) <br /> CITY STATE C 11. ZIP 9 S z D <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 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,Standard TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:03 -- ) 6 - 73 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BR.LING PARTY proof of authorization to sign is required rime <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: I zlrod Uo h)66 j—r5 ec ' ,O RECFIVSn <br /> COMMENTS: MAR 16 2023 <br /> SiM JOAQUIN COUNTY <br /> ENVIRONMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: l EMPLOYEE#: DATE: 3 /(_ a� <br /> ASSIGNED TO: j��T f� l/ EMPLOYEE#: DATE: 311(.1;3 <br /> Date Service Completed (if already Completed): SERVICE CODE: �� ] P I E: &D <br /> Fee Amount: `P's b Amount Paid D Payment Date Al/6 23 <br /> t <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P�o5�18325 <br />