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ir\eeck_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />a ctl PicfN, <br />FACILITY ID # -ti...., RVICE REQUEST # <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />'t R C^ LA Nt r.., I e"- ZI--4 V 1 0 <7 2_ Yil GI ei-1 ()et- f e a kt lio 14/ A. eC illa_,_ <br />FAC4LTY NAME <br />- in / P k K -t_ Y CA- 14 <br />SITE ADDRESS <br />'2-1—* Street Number 'Direction Sti -`-‘€.-4 Street ame \---(- ity <br />4) 5— 3 76 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site <br />/ <br />Address).u.) <br />7 Lt 1--Ii.e-t.ID NI t VV.,. Street Number 1) i R,b) ovstilettieu L) f <br />CITY STATE ZIP <br />',1.4=4 WA etlifilt_CA/C4) •P‘S--- C-4--- <br />PHONE #1 EXT. <br />«sly. 9 7 t -- i b 5-7 <br />APN # 2_ .3 5 —2 / —02-0 <br />LAND USE APPLICATION # <br />PHONE #2 <br />(10 <br />Er. <br />`601, b_5-0 D e..)c) EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Exr. <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 and ;EDER laws. <br />APPLICANT'S SIGNATURE/A(I r.Zi DATE: j,-p Y / 2/ <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 />p 1 -A."- rAinfihNT <br />TYPE OF SERVICE REQUESTED: 4.-..--2__ eo,,..f, RECEIVED COMMENTS: 1 ( <br />APR 2 1 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: (e 2.4 .3 DATE: LI I ii 1 13 <br />ASSIGNED EMPLOYEE #: TO: 2. ( 1 .-- tfcc Ss CA DATE: 1.......- <br />PI: ( 0 I Date Service Completed (if already completed): SERVICE CODE: 5 —2..3 <br />Fee Amount: g <br />Amount Paid -</Z— Payment Date <br />Payment Type V ieD Invoice # Cher.S# i&oeio s— Li t...! Received By: -7- <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23