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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of l3ftiness or Property FACILITY ID# SERVICE REQUEST# <br /> FOC6 Ccurk %( CXDWlL G8 <br /> OWNER I OPERq9R <br /> CHECK if BILLING ADDRESS <br /> I <br /> FACILITY NAME �-- <br /> lo�-e-s <br /> SITE ADDRESS <br /> 73 C�� <br /> street Number DirSection treet Name 'Zip Code <br /> HOME or WILING ADDRESS (If Different from Site Address) �?� �� <br /> Zo Street Number I ( Street Name <br /> CITY C E / <br /> tt//__�� yl�'LCJ C`i <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> (Zc9,1 ZS 4'Z ✓'tet ct t'/,< <br /> I ::] <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �0 n ' l <br /> Z ro CHECK If BILLING ADDRESS <br /> BUSINESS NAME - ��VJJ PON # ER• <br /> E-10 es l Iti(�ne�� c � i G�z-Q!i <br /> HOME or MAILING ADR SS t FAX# <br /> CITY 40C tqc�O STATE, r ZIP EMAIL i-Ak <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: 'lQ�� l�dy)'�c C, DATE: �/ , �Z3 <br /> PROPERTY/BUSINESS OWNERET 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: <br /> COMMENTS: <br /> ACCEPTED BY: C EMPLOYEE#:dgr0-:t' DATE:(2)e3 13m/Zm23 <br /> ASSIGNED TO: d���j EMPLOYEE#:a bk4P., DATE:m5/3m/2023 <br /> Date Service Completed (if already completed): SERVICE CODE: (D(p PIE: l :P(D S <br /> 1. <br /> Fee Amount:X1,c(G .()(p Amount Paid I Payment Date JC 3oI 2 3 <br /> Payment TypeI/ Invoice# lwnu.01406 I <br /> Received By: C(.J711,- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />