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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �AOOM9 ,+ SR®)$7a00 <br /> OWNER/OPERATOR �f YLA <br /> Z (� f- e f vLA HECK if BILLING ADDRESS❑ <br /> V� , <br /> FACILITY NAME Ch, <br /> i I /I f I�y r2-e3 <br /> r+�'I ��� '7 <br /> SITE ADDRESS /� �t 5 � YoSC M I+� �✓\ � �L �3 <br /> `S't(ree✓t NumberFDirec ion Street Name Cit Zi Codc <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL TOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1� <br /> YL( <br /> /Lt � <br /> YLA <br /> CHECK If BILLING ADDRESS <br /> ❑ <br /> BUSINESS NAME PH EXT. <br /> ( No\ �Ya�+ 0'l ) 9,'ZzO� <br /> HOME Or MAILING ADDRESSFAX# <br /> Zft P. <br /> Pewok <br /> Or <br /> l ) <br /> CITY G�f-�� STATE ZIP l SZ/� 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 FEDERAL laws. / / / <br /> 23 <br /> APPLICANT'S SIGNATURE: lw DATE: �r ` �` �� <br /> PROPERTY/BUSINESS OWNER PERATO 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 ItjSr�rovided to me or my <br /> representative. <br /> I"��J91 <br /> TYPE OF SERVICE REQUESTED: ME <br /> Y S f C�c <br /> COMMENTS: 5,`r <br /> sqN� 1120,?? <br /> FNV�AQ�IN <br /> HF'9LTfy pF1-4fNeN)l <br /> NT <br /> ACCEPTED BY: I) � ra EMPLOYEE#: r� ( DATE: <br /> ASSIGNED TO: Ly� a �a Ke r L EMPLOYEE#: `qV g'8 DATE: q 18 r1 x'13 <br /> Date Service Completed (if already completed): SERVICE CODE: 0!_ I P I E. <br /> Fee Amount: t Amount Paid �- Payment Date 2 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />