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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R.OO S-7 4 q 4 <br /> OWNER/OPERATOR <br /> � D CHECK If BILLING ADDRESS <br /> FACILITY NAME nn �— <br /> � 1. <br /> SITE ADDRESS ;�) �/�J '( 1,. �� <br /> St.4ui»lfer Dirt- n �ree Naihe� �Zi C dK e <br /> HOME or MNLI G ADDRESS If Different from Site Ad ress) .. 1 <br /> I e CL� Sliest Numb r Street Name <br /> CITYt� ,}' � STATE ZIP <br /> PHONE#1n— ( � EM• APN# LAND USE APPLICATION# <br /> (� 8 <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C�21 <br /> A ( // (f L Lo �2,,Q�y -c-40 CHECKifIf BILLING ADDRESS <br /> BUSINESS NAME l�T / ` PHONE -�V �. <br /> HOMEr MAILING ADDRESS FAX# <br /> r7I ( ) <br /> CITYSTATE Z EMAIL <br /> Q55&�� <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 wo 1e-tr rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT&and F <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ATOR/MANAGER [3 OTHER AUTHORIZED AGENT 13It APPLIC 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 to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C -)Guy -e PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 0 4 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> WEALTH DEPARTMENT <br /> ACCEPTED BY: a Y IckvNYI e. Ill . EMPLOYEE#: DATE: I D_ /4 ���3 <br /> � 4 <br /> ASSIGNEDTO: I—cjc G,- EMPLOYEE#: DATE: 0- �)oa3 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 6 T-3 <br /> Fee Amount: Q� I a Amount Paid � Payment Date 1 Z 3 <br /> Payment Type`,` l Invoice# Check# 12"07 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 'PR <br /> P 05 <br /> 202 l 3 <br />