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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Cov�,ljrl it v,«, FACILITY ID# SERVICE REQUEST# <br /> St-oct IPA 604552 50bm�q(p <br /> OWNER/OPERATOR <br /> � 1 \n!' � 1 � a� CHECK If BILLING ADDRESS❑ <br /> Ma <br /> FACILITY NAM 0P— D �� t 7 <br /> SITE ADDRESS _ ckOs�n/ln r�� LAY)e- �e C ��OC)�T d ) FOl�)L 0 <br /> Iti(;` reet Number Direction L 1 L W Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex• APN# LAND USE APPLICATION# <br /> (.'kq) (L 6 - g7 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESSN��E `� VA Q\ � � O � �Q„ n�1 (H NE# h S� ExT. <br /> JV HOME or MAILINGADDRESS FAX# <br /> I & a-fi� S+ � G ( ) <br /> CITY STA ZIP /t O 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 /> 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. / <br /> APPLICANT'S SIGNATURE: Q, o�� DATE: S 9 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN71 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 /> TYPE OF SERVICE REQUESTED: CAc-uuj e cF Ck vtnev Slti�p <br /> COMMENTS: <br /> JUN 0 5 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#:G�j(pC DATE:OG/WS/Zm Z 3 <br /> ASSIGNED TO: ` d EMPLOYEE M 9$1g DATE: (DG q�S 2m 2- <br /> Date Service Completed (if already Completed): SERVICE CODE: P E: �toCD2 <br /> Fee Amount: Amount Paid — Payment Date L 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />