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s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR003714Co <br /> OWNERibPERATOR <br /> '1/ll lj�7 CHECK If BILLING ADDRESS <br /> FACIL TY NAME <br /> � S <br /> SITE <br /> �ADDRESS .,n: �U�r ��C.C� ��-Iff'� �"1U�,� (J)�—(} <br /> J' :t Number Direction Street Name } ^ City Zip Code <br /> H�E)o MAILING ADDR S (If Different from Site dress) 'n �� �y�/ ���Y/�► ''n Lj <br /> J" I` Street Number �" ' g11reet Name f4' ) <br /> TY T E 2Z-:::7-�) <br /> �J <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> 119) <br /> PHONE#Z EXT. € AIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> �£2UESTOR <br /> CHECK If BILLING ADDRESS <br /> 'Un Jn Ok�Y2— <br /> BUSINESS NAME PHONE l0 D T.)Ln ID <br /> HOME Or MAI NG DR_ES�S' V - Q (AX# ) <br /> CITY (`,J �� STAT 1 ZIP EM IL �l t� <br /> UYICt .cc Yyl <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. ^ I (, ^ ^ <br /> APPLICANT'S SIGNATURE:Omyu& C�km� DATE: (tel' <br /> v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAR7Y_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 /> TYPE OF SERVICE REQUESTED: I V e c LI Ft� <br /> COMMENTS: w <br /> �SEP p s� <br /> H,Z-,*Q/ CO! 3 <br /> �OEP,yRNTACvlY <br /> ACCEPTED BY: (fes `J EMPLOYEE#: DATE: <br /> ASSIGNED TO: G2 r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: © PIE: l <br /> Fee Amount: i �_ Amount Paid I Payment Date Gl 2� <br /> Payment Type le/y n Invoice# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />