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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />,Type of Business or P erty , e ev-1 <br />FACILITY ID # - (k SERVICE REQUEST # <br />se-cog b Li ci I <br />OWNER / OPERAT <br />nn,.1 1/10.-• ---7414.QA' CHECK if BILLING ADDRESS <br />FACILITY NAMEakkA 1.:), - <br />tcA.ouLs itYr.C,(4- <br />SITE IADDRESS <br />110 likl i.,1 40(.6414.)Street Number Direction 4 a bXrAtili Street Name g-rialski"\-- <br />4S-2_61.— <br />Code <br />HON or MAILING ADDRESS Different fro Site <br />(1 ta:17 I (MA Yin Street Number Street Name <br />CITY <br />\ A re) •/ ce% 36 <br />PHONE #1 Err. <br />(Chlk) 1;1 4 -OG di) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />(104 ) cZY-4— C171-0 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR s.,44As CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <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 this form. <br />I also certify that I have prepared at n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, St dards, STAT and FEDE laws. <br />APPLICANT'S SIGNATU DATE: <br /> <br />PROPERTY / BUSINESS OWNERg OP RATOR / 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 <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 an he same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />- <br />1:) <br />COMMENTS: (4 1..ettiA4. <br />_J <br />i'/Alie • <br />Sigh/ <br />'. JOAQ 1 3 2023 <br />Ai ,f41111/ 0 1-1141 CO <br />t rti D Allevr tiAlr)- , qt. <br />' 44N... <br />ACCEPTED BY: EMPLOYEE #: zo DATE: 3 1 3 ( 2_ 3 <br />ASSIGNED TO: EMPLOYEE #: 9 s 2..../ DATE: 3 i 3 / <br />Date Service Completed (if already completed): SERVICE CODE: 6 ) 41 P I E: 1 boa.. <br />Fee Amount: I, 56, Amount Paid 4 ,r7.7,, suLre Payment Date oi 23 <br />Payment Type 6a4 Invoice # Check # 10 4-612(16 Received By: aly-z1 <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003