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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> mob( <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> P. > .J <br /> FACILITY NAME <br /> P�`IC ,i•-/t"SS C-L <br /> SITE ADDRESS j CAS- +oGZn►IA. �7T STocTo� GIS z o� <br /> 73C' Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (�,s,y y G�v 3 <br /> 2 5 S Street Number Street Name <br /> CITY�.. STATE ZIP <br /> �-To G��t o K,A `?S Lo <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (zdt)16 - 5 L4,00 <br /> PHONE#2 Ex-r. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> ` 3 i"I mac: ( 20-1)`r 3 t- S(-1 0 0 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE CA ZIP q> LC 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 applicat• n and that the ork,to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SJ��FDERAL I8W . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 04PERATOR/MANAGE ❑ 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 prOVI �to me or my <br /> representative. (►� IV <br /> TYPE OF SERVICE REQUESTED: CElo/ <br /> COMMENTS: APR 14 1023 <br /> SAN dOAQUIN C <br /> HEALTH p p 7y <br /> NT <br /> ACCEPTED BY: l>>V" lit-Z�- EMPLOYEE#: (i ( t j DATE: <br /> 01AIt'kIZQ�23 <br /> ASSIGNED TO: EMPLOYEE#: r'i�''I DATE:Lr,y/i y I2m-Z-1, <br /> t <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: (o(Z <br /> Fee Amount: 1 (✓ Amount Pa4p Ig (� Payment Date I Z j <br /> Payment Type Invoice# Check# 1�O�S? f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />