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SAN JOAQUIN COUNTYQFNVIRONMENTALIF�ALTW U PARTMENT <br /> SERVICE REQUEST �/ IZI S , S-j- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ��CGS l �GICa S SLC <br /> $ITE ADDRESS <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 2�'3 L)'-'y <br /> Street Number Street Name <br /> CITY STATE „ ZIP S S S S <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (ter) x(96-r>� 3 114 ti14 <br /> PHONE#Z ExT. EMAIL., BOS DISTRICT LOCATION CODE <br /> (Got ) i�- �6r✓-- oz6S IV)-Fo C Ckic�\�uc�s,(C'0' 14 ti � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �oS-� C�tl1rP( �+�1/(I'. vc �I CHECK If BILLING ADDRESS <br /> BUSINESS NAME C�fc�l �UCa S Zu PHONE# EXT <br /> (2-,1 �' X 60 ozGs <br /> HOME Or MAILING ADDRESS FAX# <br /> 1213 Rry\rocK <br /> CITY ^ ,v 1Q�k a STATE / A ZIP c n EMAIL <br /> ✓"l d �/`� �� S S S �11�0�i� Inti col-�itCo S,Cv/t� <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 /> APPLICANT'S SIGNATURE: :._ DATE: <br /> PROPERTY/BUSINESS OWNER 1P OPERATOR/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 It Is pcp^vided to me or my <br /> representative. fi� ry Y <br /> TYPE OF SERVICE REQUESTED: rTt�CFS <br /> COMMENTS: MAY <br /> O <br /> l 3 2423 <br /> SA SN�q QUIN C <br /> NEq�TN Up�PAR� ��� <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if a eady completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type �l Invoice# Check# f D;L7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />