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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/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> v,erc-) <br /> SITE ADDRESS <br /> c� ISO C— � �I-, C <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRES71f Different from Site Address) <br /> Q Street Number Street Name <br /> CITY STATE ZIP <br /> 5�6 t'40 ri S .2D b, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION <br /> 7/ 5,- a 1�o 5- <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> 3 C-n-tail <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REqUESTOR <br /> S o r r G -Y U Z r re—Z CHECK If BILLING ADDRESS <br /> BUSINESS NAME / C PH NE p EXT• <br /> t%er'/G 7Carr1 CCY( G c�lY1G� l0 �'/ Z "lt2—SB�G� <br /> HOME Or AILINp ADDRE r FAX# <br /> CITY 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. <br /> APPLICANT'S SIGNATURE: kjztS2 Crc')2 DATE:DS' l�- 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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It IS provided t0 me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: ���, t Z yl PAYMENT <br /> COMMENTS: RECEIVED <br /> MAY 17 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: L C r S EMPLOYEE#: k—A DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 IilPIE: b <br /> Fee Amount: S ` Amount Paid �� Payment Date <br /> Payment Type v Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> 7 <br />