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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />PAU) 0.7 5 3 Co <br />SERVICE REQUEST # <br />SROOS 71401 <br />OWNER! OPERATOR c y • <br />VI I r' 0 -1-C R (:).-Te 4:7)r— ' rf --- i-- 0 CHECK if BILLING ADDRESS <br />FACILITY NAME S 0 NA C7l ryN --1.2c. ir—LJ...*----- li — r b <br />SITE ADDRESS 3 -2.40 0 <br />Street Number Direction <br />Y-4..r11.- e• -7-.-J si-. 2ts <br />Street Name <br />-Tirz%i itc--7 <br />C <br />CA--- 1D4 5 <br />Zip Code <br />HOME or MAILING ADDRESS If Different from Site Address) <br />7z1-- Street Number <br /> <br />Street Name <br />CITY ZIP <br />Tr-t3 <br />PHONE #1 7 <br /> EXT. <br />TATE c- / 7 T.S <br />(2-‘39 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />I2L61) 3( gl--1- c=1' 4 <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS EJ <br />BUSINESS NAME PHONE # EXT. <br />( ) <br />HOME Or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE 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 arid FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATE) / MANAGEh 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 />lk - . .. . PAY MEN <br />TYPE OF SERVICE REQUESTED: Consu - a---Ion/ 40 a• ii .. - VI • .' - RECEIVE COMMENTS: • <br />SEP 0 5 20: <br />SAN JOAQUIN COL <br />ENVIRONMENT)! <br />HEALTH DEPARTM <br />ACCEPTED BY: 4 Jeff Ca_ rr UeSC0 EMPLOYEE #: DATE: 9 _ 5 _ca 3 <br />ASSIGNED TO: K sae a nne Lif\haveS EMPLOYEE #: DATE: 9 _ 5 -gs 3 <br />Date Service Completed (if already completed): 9 _ 5 _0 3 SERVICE CODE: p Co 1 P / E: I Co e,Q, <br />Fee Amount: 1-1(sa. 0"9/ Amount Paid c_tncoa. ay Payment Date <br />Payment Type kil A_ Invoice # Check # o -3 ---13(,e, ReceivedBy. . <br />DATE: <br />3 <br />NTY <br />NT <br />END 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />03/22/23