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. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S IQ, Wgv-+611 <br /> OWNER/OPERATOR <br /> ANA(3EL M 0 a k ��nen n CHECK If BILLING ADDRESS <br /> FACILITY NAME .rQ�T� T�C-0 �'`\, t�,�C� CALI��` I <br /> SITE ADDRESS 4 3() S 7 n�J N 1 A �- I � �(,J 4G'L�JJ� q 5p O� <br /> Street Number Direction CA( �"Sire`et Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 32-2-0 ✓tiC 2���(�D LT Street Number Street Name <br /> CITYOG� f STATE ZIP <br /> CA (9 SZ09 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (z(M) +07 4 I OZ <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> 5C�? Otn f)I e-M)0o?)05 )GIO UG -,04 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / � � p <br /> A��e Q �� �1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME ,�L I PHONE# EXT• <br /> t-C) t7kC F>l�Z1rz�� Chi_I ( 21902- L(I UZ <br /> HOME or MAILING ADDRESS FAX# <br /> 3zzb r�Ef�e-;Fi Env C:T ( ) <br /> CITY S-) �G1 STATE ZIP EMY1L I I)OLo <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 andRA//laws. <br /> APPLICANT'S SIGNATURE: L�lP�1. DATE: Ob)05 �Z- <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 tlnfDAY NI'to me or my <br /> representative. RECEIVEDr <br /> TYPE OF SERVICE REQUESTED: '�0 G V �l t c(o � V1S e LGA <br /> COMMENTS: <br /> 6AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: U EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 3 <br /> Fee Amount: '�� Amount Paid 's'& Payment Date 6 Z 3 <br /> Payment Type C(� Invoice# Check# Received By: <br /> Cm,, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />