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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FAQ)CDCb5 e‘e) <br />SERVICE REQUEST # <br />SRZCD S-4 2:4-5 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />11) /1 fler'5 r C/f <br />FAciLirv NAME , <br />Kt/ C 1 --1 C 11-04e1?)\ 10 C 1'6? 10 <br />SITE ADDRESS <br />/2)3 k-ipnviipeecember 1 Direction <br />, 1 <br />I }-0Yril7c12 1-N Street Name <br />cir cid. it) n <br />City <br />CIS-2 1 0 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />q 2 3 q Ocui 1- 9.1-Ne c 4 Street Number <br />Deth-kd st-)-c d , L14 0 aove <br />Street Name <br />CITY c, <br />d <br />V4 C- b-cvrn erArtl <br /> <br />STATE ZIP <br /> <br />(0 Q S-1 2 4 <br />PHONE #1 Ext. <br />(C I 4 ) q 6 - 6 V )S- <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />041,1 vl e v j jc Q.A CHECK if BILLING ADDRESS <br />BUSINESS NAME n ,., <br />.A. C- rc( rl %Alan J IrYI ot 91 kr_-‘ <br />P HONE # <br />( cii6) 'c't t — <br />EXT. <br />HOME Or MAILING ADDRESS <br />el ), 0 0 C tl a (4 Q )--a-f. J J <br />FAX # <br />( ) <br />CITY <br />C cl L'ict_ ini e ri I <br />STATE ZIP <br />C ICI 0 --1)"2- \-i 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: <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 />TYPE OF SERVICE REQUESTED: CV‘CAnC) R a Ocov) t-fir 5 Vo P PAYMENT <br />COMMENTS: <br />RECEIVED <br />OCT 0 9 2023 <br />0,.N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ?V i (Lyky-).e. EMPLOYEE #: DATE: <br />ASSIGNED TO: EY- a o c_ k S CC EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 02(49 k 7:,7 , z <br />i .2.4;..15 Fee Amount: ( F it 4,2_ OW Amount Paid 6 a— Payment Date / b <br />Payment Type r AA Invoice # Check # 3 q S, Receiv d By: <br />DATE: le/ SI 20 23 <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23