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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST IPQOS <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5940B 1 2}-4 <br /> OWNER/OPERATQR <br /> ,/ N� CHECK If BILLING ADDRESS <br /> FACILITY NAAM_E Ko K40 <br /> re LRS L L G <br /> SITE ADDRESS © � Fg�- W <br /> Street Number Direction Street Name Cit ZipCode <br /> HQuE.Oi4IlA1HwADDRESS (If Different from Site Address) ' < l <br /> '9t/ 1 d�S rV Q ismber r � 3treelName !! <br /> CITY STATE ZIP J <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 656-S15- 3'I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> —f' /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME L I Al P �/ _/B�J __ / ) L / PHONE51 # �_ Dn EXT* <br /> HOME or MAILING ADDRESS �i1�JC(J� (i C FAx# L 2— <br /> HOME <br /> 1 asks 1-J(9 V ( ) <br /> CITY T /n pf— > STATE C> L1 ZIP <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 <br /> or activity 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: �� 1 � h DATE: <br /> L.9,5)20 2 <br /> PROPERTY/BUSINESS OWNER/p1��L� OP RATOE R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CAM 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. "^�' PAYMENT <br /> TYPE OF SERVICE REQUESTED: Mob 1l e Rud bm$ loft hoh RE ElVprj <br /> COMMENTS: <br /> i U 6 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:-aT tCknne, M EMPLOYEE M DATE:2) z'�`•22 <br /> ASSIGNED TO: Vi d tXQ P EMPLOYEE M DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: WO% P I E: �(0(D3 <br /> Fee Amount: V(O L om Amount Paid Payment Date 23 <br /> Payment Type C� Invoice# Check# Received By: <br /> C 70d ( 32110 <br /> EHD 48-02-025 SR FO (Golden Rod) <br /> REVISED 11/17/2003 5 <br />