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SAN JpAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # .-• SERVICE REQUEST # <br />SROO 87454 <br />OWNER / OPERA R h <br /> ul <br />A <br />CHECK if BILLING ADDRESS fl k e er‘o <br />FACIUTY NAME t- i <br /> <br />/ 1-- C) rof y <br />SITE ADDRESS <br />4:1) SO/NO tliiiikNumber Direction - OVN 0 V-06treet Name S.k 0 Gki9 A Cip-e-1;23 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />( <br />Street Number <br />2)0( <br />Ho iil -k" Y.- Street Name <br />4_50c,'S 4 0 (i STATE ZIP <br />PHONE #1 ExT. <br />(20.1 ) CO 00 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />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 />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: A r DATE: I I (IL) ( a 23 <br />PROPERTY! BUSINESS OWNER tO 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. P . iwir. m -, <br />TYPE OF SERVICE REQUESTED: PECE-`"1 IVED , <br />COMMENTS'. (:)yEc__,1 _ NOV A,c kru--, 2 0 2023 <br />SAN ,,, ...,AQu,,, <br />EAIVIRON" couivrv <br />1141-1-Hoepm6NTAL. ARNENT <br />ACCEPTED BY:----Th EMPLOYEE #: 7 -23 DATE: <br />ASSIGNED TO: <br />7 <br />EMPLOYEE #: DATE: t 2,0 2,3 <br />Date Service Completed (if already co p eted): SERVICE CODE: P/ . I b 0 2.. <br />Fee Amount: , le , , 4.)7,... Amount Paid 162 . 6D Payment Date /1 2_272... <br />Payment Type ezt66,.._ Invoice # Check # Receive By:475. <br />Title <br />7 1-(‘ t O S FORM (Golden Rod) EHD 48-02-025 <br />03/22/23