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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID ft SERVICE REQUEST if <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME i 3 C {--(-___ <br />SITE ADDRESS ii4 ..-S-S.' <br />Street Number Direction <br />GLIA ‘i 14-e,5 3)1--- <br />Street Name <br />doc_klle'Ll <br />City <br />q2 0- <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />is!-)- <br />PHONE #1 Ext. <br />(g ) # I o -3661' <br />APN N LAND USE APPLICATION # <br />PHONE 02 Ext. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <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 />COUNT) Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: r <br />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 anted 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 />TYPE OF SERVICE REQUESTED: kl w (11,4L <br />Ktutivci, <br />COMMENTS: tle(C+-Ye"--y-L ---2_ <br />Piii 9 H14, <br />P(..„...L.A„.5 APR 27 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />NEALTH DEPARTMENT <br /> <br />, cool <br />ACCEPTED BY: <br /> <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: 0C(Claitt. <br />EMPLOYEE #: DATE: <br />1 -77 <br />Date Service Completed (if already completed): SERVICE CODE: <br />C-3'Z -27 <br />P/E: /66 i <br />Fee Amount: 40 _ Amount Paici ji /o , Payment Date 4/ ,/) 2.,--5 <br />Payment Type /"9J-:\ Invoice # .„Chea # 1 W jo 1 11 z I Received By: iiha,,,1 <br />PROPERTY / BUSINESS OWNE <br />If APPLICAN iS no the BILLING PARTY, przet f authorization to sign is required <br />ERATOR / MANAG7 OTHER AUTHORIZED AGENT 0 <br />DATE: 14/1 <br />re resentative. PAYMENT <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23