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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FA WW1 CO 4 <br />SERVICE REQUEST # <br />5ROG 3'75 50 <br />OWNER I OPERATOR <br />CHECK if BILLING ADDRESS HETA-Z, 1- __L&)c, <br />FACILITY NAME 1 <br />l- onoi 'Sohn Ser'S *a2ICI .g <br />SITE ADDRESS 3 t4,--/ <br />Street Number <br />N. <br />Direction <br />t,\I; \S0\ w al <br />Street Name <br />s-i-oc-Y--kinin <br />City <br />9 5ao5 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Po Row 0-40 6C6, Street Number CA- Street Name Ci Cg '3 Li <br />CITY (--) STATE ZIP <br />__4e,t2A-AnekiTc.3 cii- 9Cg3/-1 <br />PHONE #1 Err. <br />(W9'10670'7-6 <br />APN # <br />1 5 3- 00 .-.4- <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) AA ( 4 <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r-, <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME L on ci —so vi ,....\ si \ ver ,s 3go, 8 pmE #0 qe 76 .7_6 Err. <br />HOME or MAILING pDDRES,5-) <br />PO OK' 21D 6 -C6 <br />3 FAX # <br />( ) <br />CITY STATE ZIP ys-g 4/ <br />ErgITA,ZJ __.C4ce/9i4EN TO <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 a a FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: /2e/,2_ 3 <br />PROPERTY! BUSINESS OWNER Ell PERAT R / MANAGER 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 />TYPE OF SERVICE REQUESTED: Co y\k.A kl-a..4-inyl _ CA k ccAcv a 4. c)jr PAYMENT 1,,ip <br />COMMENTS: RECEIVED <br />DEC 20 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: S . B et II LI ja_k vi EMPLOYEE #: DATE: <br />ASSIGNED TO: C . i\j\ u r. 0 EMPLOYEE #: DATE: I a _;_o _.3 <br />Date Service Completed (if already completed): SERVICE CODE: oc o i PlE (0 02 <br />Fee Amount: IS 4a Amount Paid /6, Payment Date <br />y! <br />Payment Type .? A_ Invoice #51,1 eic # / q ? 3 ((p Received By: gi <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />Well (VI O L' LOS S