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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST -------------, <br />Type of Business or Property FACILITY 1D # SVICE REQUEST # <br />1 /fl l 1YE-1- 1 --"""- <br />OWNER I OPERATOR <br />CHECK lft3lruNl aADDREae_❑ <br />M +, <br />\ <br />FAGiLtrYNAME <br />PR -M -H 0IV,)&less 6p ?�o 0;1911-F <br />SREADDRESS fit <br />AUG 0 3 2022 <br />Stn.l Ni mbor Dlrectlon Strut Nom <br />cl Cod• <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Q{ 1 y�ii` <br />1 �^ Slia.t Number <br />• l l. <br />CITY �j�R(ye <br />sTATk zip <br />PHONE#1 EXT. <br />N# <br />ENVIRONMENTAL <br />LAND USE APPLICATION 4 <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />PHONE02 EKT• <br />EMPLOYEE#" <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE RE, 1U1:S'.l'OR <br />REQUESTOR �1 t 1 J '� <br />�WV �j CHECK If BkLLINO AD0RES5� <br />BUSINESS NAME Q I �� PF{ONE# n ' <br />HOME or MAILING ADDRESS FAX# CJ <br />N t 4 t"O 4P-' t ) <br />CITY f Mtt�7� STATE ZIP tYiJy <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 ENVIRONWNTAL RMTH DEPARTMENT hourly charges associated with this project <br />or activity wilt be billed to. me or my business as identified on this form. <br />I also certify that I have prepared this a I' atioa and that the work.to be performed will be dobe in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar S TE a�F-LAPPLICANT'S SIGNATURE:r DATE: N}9' I C?' r1-OZrL <br />PROPERTY / BUSINESS OwNER4T` ERA R / MANAGER ff OTHER AUTHORIZED AGENT CI <br />IfAPPLlGWTis not the g/LLINOPAR proof of authorization to sign is required Tine <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or opeirator 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 •assessinent <br />information to the SAN IoAQUIN COUNTY ENVIRONMENTAL HaALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. rn A \/ n = R l -r <br />TYPE OF SERVICE REQUESTED <br />1 /fl l 1YE-1- 1 --"""- <br />COMMEwn: <br />M +, <br />\ <br />AUG 0 3 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#" <br />DATE:' <br />AssiGNEDTO: <br />Q ops <br />EMPLOYEE#: 94s� <br />DATE:, 8!� <br />Date Service Completed (if already completed); <br />SERVICE Cone: } <br />P I E: <br />Fee Amount: <br />p <br />Amount Paid <br />+ T 2 ® <br />payment Date <br />f <br />payment Type <br />t ;, ; <br />Invoice # <br />Che N A Gr ¢' <br />Reeelvad By: ytj <br />EHD 99.02-025 SR FOA(Golden Rod) <br />REVISED IV17/2003 <br />Scanned with CamScanner <br />