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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />(-2..a4D B-io 83 <br />OWNER / OPERATOR <br />LL) 6---9_1 i . I-- K CZAA_A-- CHECK if BILLING ADDRESS <br />FACILITY NAME i(/V i/V 6 ./-- j/i 1 - iLi i v 1 AA t-f _s ge ft-, 6 )/ c <br />SITE ADDRESS I 6. 2- o / <br />Street Number <br />__C <br />Direction <br />41 4/1- I a-4.,-- /Q4 • <br />Street Name <br />L e, 4 A -0 j ) <br />City <br />s -33 o <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I 0 2 3 7 Z_ crio).) L cc,--e_ Street Number <br />2_6 /JP A L a_-e_ <br />Street Name <br />CITY STATE ZIP __, <br />c-/C--- &Z. <br />PHONE #1 Err. <br />Vcc)) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Env& ,, , <br />iii /10, e'••J -17V C k 0 / I • / / C <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: Li. <br /> <br /> DATE: / I 2_ 3 <br />PROPERTY / BUSINESS OWNER 1:1— OPER trkaiR I----.±-'1.0THER AUTHORIZED AGENT 0 <br />If APPLICANT IS not th LI ARTY 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 />TYPE OF SERVICE REQUESTED: \'IR kk) (Sy_t_4( <br />• NT <br />A-NrcA--(-) er RECEIVED <br />COMMENTS: <br />AirairiNnwc <br />I AUG 1 2023 <br />'SAN <br />j <br />AN 0 <br />Qu <br />EtiviR0N uNTY HEALTH DE pAn4EN <br />o <br />TAL ,vx -rlinENT <br />ACCEPTED BY: v v tit c t 0 c.., EMPLOYEE #: DATE: 2-1 -13 <br />ASSIGNED TO: lei k a Aq s EMPLOYEE #: DATE: si — 2.-( -13 <br />Date Service Completed (if already completed): SERVICE CODE: < .2.3 ['P/E: ((,367/ <br />Fee Amount: 44er s-6 .- Amount Paid _10nt 1 ue n ..---- u P <br />Payment Date <br /> <br />Payment Type otwd Invoice # 14-0,1gykr 4 : [ 01-06? I (1q)....fteceived By:t d0 ii -7/ <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23