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� C O-ZE, 2)�' 0 <br /> • SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS 19 <br /> FACILITY NAME ( C,C <br /> SITE ADDRESS 35.�� �(V r\- v-\e 26'/ <br /> 6 <br /> Street Number Direction Street�e —`1 <br /> HOME or MAILING ADDRESS (If Different from Site Address)Ll <br /> 2C 5 Street Number i3 L( L A t/ Street Name <br /> v CITY STATE ZIP <br /> 5tcc {t 0 yl C " 2C. <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (Z`9' 64 - ' 115 <br /> PHONE#Z ExT• EMAIL BOS DISTRICT LOCATION CODE <br /> MIA ) 5N -4117 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> PC- A S >`l r CHECK If BILLING ADDRESS <br /> R I F t <br /> BUSINESS NAME _ \, PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> 9CC; CA ri C � / ( ) <br /> CITY 5TC'C ,,`o V L� `fPJ 2C' (j �M�IL 4Z CCC',C �' <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, StandaSTATE and FEDERAL laws. <br /> J APPLICANT'S SIGNATURE: SI V71h DATE: — I - 2-3 <br /> PROPERTY/BUSINESS OWNER 91 OPERATOR/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 provided to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVIED <br /> SEP 1 1 2 3 <br /> SAN JOAQUIN COL Niy <br /> ENVIRONMENT <br /> ACCEPTED BY: �Autcc� -o EMPLOYEE#: DATE:c1 t 1 t�Z3 NT <br /> ASSIGNED TO: �1`^�r ��� EMPLOYEE#: DATE: CI 1 11 1 Z3 <br /> Date Service Completed (if already completed): SERVICE CODE: PI :vov2 <br /> Fee Amount: \ Amount Paid — Payment Date d--0 2 <br /> Payment Type I Invoice# pt-ck# $� b � � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />