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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5RQ0 8-- kCAcP <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FAciuTYNAME flat- Scr�oPS <br /> S aC <br /> SITE ADDRESS —�-$--} �gp,, r \niY�_�/ G <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) P � W <br /> Street Number Street Name <br /> j <br /> CITY STATE Z <br /> ""II A 3 3 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (510 50�) -o ) 3rj <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J �I ( r. �2 F:=- <br /> S_ ^ I LU LCHECK if BILLING ADDRESS❑ <br /> �J <br /> BUSINESS NAME 1� r_ S�OIS �j PHONE# ExT. <br /> 1 (r;(6) owl -a 3 <br /> HOME or MAILING ADDRESS P, q) i FAx# ) <br /> CITY M N l STATE Cn ZIP 61 tG' 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 FED E L la <br /> APPLICANT'S SIGNATURE: DATE: ct /i /2b 2 3 <br /> PROPERTY/BUSINESS OWNER❑ RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 prC) or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: MCAc%' II2 f C&)6 �uY1Sll�}t�}iC Vl CZ C. ccc -M CC0,k> ED <br /> COMMENTS: 18 2023 <br /> SAN JOAQUIN COU <br /> HEANVIRD pAEN7AL T/ <br /> ACCEPTED BY: 6C t C M EMPLOYEE#: DATE: Q`t,a k?,1 <br /> ASSIGNED TO:CWLL&CA iC" (�. EMPLOYEE#: DATE: Ct,ltd�Z3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: $\(o`Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# 16 F'7 76 /c5 I Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />