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Pi�0Sy-ES 2y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR I <br /> DD CHECK if BILLING ADDRESS <br /> FACILITY NAMEA142 =1:1:S Ll <br /> SITE ADDRESS <br /> Street Number Drrection� 7�A,'Na Ke Cit G ZCode <br /> HOM or MAILING DDRESS (If Differe t fro Site Address) 4J <br /> / •Y; Street Number ✓ `t 4 Street Name r <br /> CITY�J/J ]qzip <br /> PHONE 1 EXT. APN# LAND USE APPLICATION <br /> (7 (.11 3 0 00 <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME (/ PHONE# EXT• <br /> a 5 (Zi` ) 3 G} .. DO <br /> HOME or AILING ADDRFS Or FAX# <br /> [ ( ) <br /> CITY STATE ZIP EMAIL/ ` <br /> cc <br /> �'1p <br /> ,C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized age 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 applicati n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE Id FEDE AL.I WS. <br /> APPLICANT'S SIGNATURE: DATE: `�/- ` - L <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not e BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE k4FORMATION: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 provide1� or my <br /> representative. P_ <br /> TYPE OF SERVICE REQUESTED: RECEIVE <br /> COMMENTS: <br /> JUN 16 202 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:e' -kC'IRCI� EMPLOYEE#:qg�s DATE: (p�Z(o k 23 <br /> ASSIGNED TO: 11_0.(Je.Ct-y\r)e. EMPLOYEE#: LV589 DATE:& 123 <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: ti(,Cp'3 <br /> Fee Amount:$11,50.00 Amount Paid 1 S�o � Payment Date � 2 G � 2 ?� <br /> Payment TypeU�S Invoice# C ck# b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> -./ <br />