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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fri( O-: 88 -� SROOS749 3 <br /> OWNER/OPERATOR Ca 2(�'x E-fo, <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME EL Lrde4oe- /1.4L r-, <br /> SITE ADDRESS � 0 J ( �) j�q��( �4- `_Oc e�©� �n <br /> treet Number Direction `r S Z0 Name `C CI od`e F/ <br /> HOME MAILING ADDRESS (If Different from Site Address) 1G?e/ v� <br /> r / <br /> C � v e- Street�'. <br /> ber I 'C at f Street Name <br /> CITY L / STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> r , ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> yl Ue yye-(0 CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# _ xT <br /> ro <br /> HOME or MAILING ADD ESS FAX# <br /> ( ) <br /> CITY ^ ST TE ZIP EMAIL _ <br /> Z2,2 a C 12224L <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or aut ized agent of Sam r� <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, nd _ laws. ----APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ATOR/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 provided t0 me or my <br /> representative. �m <br /> TYPE OF SERVICE REQUESTED: Ck ar1 e C)L�i1eY Ste' p �� <br /> COMMENTS: I VES► <br /> DEC U 4SAN X23 <br /> N'RONM cou <br /> �OEp,�TMAC <br /> Ivry <br /> ACCEPTED BY:`ev\c: on-e (u\ EMPLOYEE#: DATE: i <br /> ASSIGNED TO: f :��G� 6 EMPLOYEE#: DATE: 3 a_4 _d"1 3 <br /> o), <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P 1 E:J(oO3 J <br /> Fee Amount: -s «0 a Amount Paid / � a —, Payment Date <br /> Payment Type Invoice# ` Check# Received By: <br /> EHD 48-02-025 SR FORM Golden Rod) <br /> 03/22/23 Wo S 0 <br />