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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />Si2OD•gol —n <br />OWNER! OPERATOR , <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ‘‘ <br />El Goa) iroplcos\1 /44- . <br />, SITE ADDRESS -cvoufx vi, ch <br />--Street M.:ter Direction <br />,(-13i1;fk csri (.(1\ 1) - • <br />7.--14 0 : '''''' \ Street Name <br />i'\()C,K-\ 0 i) <br />City <br />qb g 03 <br />Zip Code <br />HOME or MAO& ADDRESS (If Different <br />V3C1Q, . -j.• <br /> <br />6 Cj f3D <br />from Site Address) <br />54 . Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 #1 EXT. <br />(9 16 ) 64 . q63(-I <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br /> <br />fll 412 o6 111(), 94; ilc----- <br />CHECK if BILLING ADDRESS <br /> <br />BUSINESS NAME' ' • f--.. , <br /> <br />' (54tan -I: 0 \0 1 Ca \ I <br />PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS <br />I i 0.Q . ,c_; . Do piA 0 .3+ <br />FAx # <br />( ) <br />CITY :101.K10 0 CO, <br />STATE , r:Qc 6 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 />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 I <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! 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 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 to me or my <br />representative. <br />cs-lk -•„„,...., <br />TYPE OF SERVICE REQUESTED: -.00(.1 (1),/aku c NT t /ie• ` / VE0 <br />COMMENTS: .....\ocA Niej_ /..v.12,titt ectiej, MAY 3 , ,, <br />SAN <br />r 423 <br />JoAQuiN <br />- 1,,,AIVIR 0A ,.. COuvr , <br />""Lril DE'vpfilAirAL ' r AP riviE.Nr <br />ACCEPTED BY: 11U., EMPLOYEE #: DATE: 43t 2 S <br />ASSIGNED TO: \A$5 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: (As ( PIE: 1 (00.3 <br />-- Fee Amount: lii.,,tt it) Amount Paii2f/5-6 d 2O Payment Date <br />Payment Type Invoice # Check # Received By:6,--- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23