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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # r- SERVICE REQUEST # <br />5R0035q2,3 <br />OWNER! OPERATOR CHECK if (-4 e. ry\ a q cis c_Ak e...Y-44._P---fi• <br />BILLING ADDRESS 11 <br />c— <br />FACiLiTY NAME I <br />1— gl, Or <br />SITE A DSS ADDRESS <br />(Ia. g.... Street Number I Direction <br />me)(-0A Ci \) -\ -Dk '3\ .D4(' Street Name Q, \ C-- (1. k % City <br />95 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EX 1 . <br />(VA ) li t ci _,T, 9 0 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <br />APPLICANT'S SIGNATURE: Ofl.e--//P`-1 DATE: 0 g., <br />PROPERTY / BUSINESS OWNER cr.- OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT El <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabPAYMENTe time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 0 2 2022 NOV <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: 2.13 DATE: I/ /4 1 2 - ?- <br />\ ASSIGNED TO: ka/n1kile‘ EMPLOYEE #: I b S4 DATE:/i I li 2, <br />Date Service Completed (if already completed): SERVICE CODE: G z...7.) P E: ( boi <br />Fee Amount: Amount Paid 17( g Payment Date 1 1/ 2,40 q)/(40 <br />Payment Type Invoice # Check # Received By: <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 <br />or activity 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 and FEDERAL laws. <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003