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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property tFACILITY ID# SERVICE REQUEST# <br /> /�UIW Z-�L (D Z SKWB—i(DB-1 <br /> OWNER/OPERATOR 1n^ `'� //5C <br /> y \I'�j c (/\o/� CHECK if BILLING ADDRESS <br /> FACILITY NAME C6T�C <br /> SITE ADDRESS ✓ a� <br /> Street umber D�tlon v` L� Street Name Ci �Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) / "J 0-treat Number Street Name <br /> CITY � �n,d�,� STATE �� ZIP <br /> PH NE ; nn� I E,,,,-r, # LAND USE APPLICATION# <br /> PHONE#2 5�j l ExT• BOS DISTRICT -7 LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1/�f` KAT �G CHECK if BILLING ADDRESS <br /> BUSINESS NAME i/L.,.�/�nl ✓ J�( PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY CV-/I ,M n I/1-�( STATE C 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 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 <br /> EDERA .laws. DATE' _] <br /> APPLICANT'S SIGNATURE: \ e i��/d 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C V)CLn e OC O LQ n e li S i-v P <br /> RECEIVED <br /> COMMENTS: <br /> AUG Z 1 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:'b'('tC,V)r2 M EMPLOYEE#: DATE: ZZ 1'Z3 <br /> ASSIGNED TO: Lyd iG 'TJ EMPLOYEE#: DATE: (Zz (23 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: -2- <br /> Fee <br /> ZFee Amount Ib2 Lv m Amount Paid 6a l Payment Date d' 2, <br /> Payment Type U1 C) Invoice# g�edk# S S'— Received By: l <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />