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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F�U001'I�O SQccgi'oS <br /> OWNER/OPE TOR <br /> \ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> �! m\( OAC A TKON S-T C)0 -Tc> 'k) <br /> SITE ADDRESS 2cj j �^GI C A-rc- �7 'iU�_w -1- zc <br /> Street Number Direction Street Name Cit `I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Y/a 1 �x e (\I CA A CA C' ? Street Number Street Name <br /> CITY STATE ZIP <br /> s �� �� ip s- <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (49) yUU ?o <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> (do ) SS9 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR1-1 <br /> G �' f e. 1 CHECK if BILLING ADDRES <br /> BUSINESS NAME `Y A ! a PHONE SSD# UO xT <br /> N A kR � ' S1oc To.L <br /> HOME or MAILING ADDRESS1 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 811 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,STAT d WDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/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 8s soon 8s It Is available and at the Same time It IS provided to/me Or my <br /> representative. PAY <br /> TYPE OF SERVICE REQUESTED: Tbo6F(Gl,v1 - EcE j <br /> COMMENTS: AUG 14 <br /> 20 <br /> M6� rrK <br /> ACCEPTED BY: EMPLOYEE#: DATE: I z <br /> ASSIGNED TO: ftw EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z�'� P I E: 1(0 t <br /> Fee Amount: J I / • Amount Paid co 2 f Payment Date a 23 <br /> Payment Type I lit Invoice# Ck►ecK• -� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />