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Type of Business or Property FACILITY ID # <br />< h n. i u i A <br />B M. il6 Te C A <br />Direction <br />APN# <br />BOS District Location Code <br />G A c. i A£ h n, | J, ■> £. <br />\J A u C £De u <br />BC T <br />/ 2o 3 <br />JUN 0 7 2023 <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />A <br />_____________ Date: <br />Other Authorized Agent <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />o 0 t $ T O <br />City <br />payment <br />fJEeevED <br />SERVICE REQUEST # <br />3/208^805 <br />? $-3 <6 <br />Zip Code <br />Accepted By: ___________________________ <br />Assigned to: \Jic/cJ) <br />Date Service Completed (if already completed): <br />Amount PaidFee Amount: <br />Payment Type f ; <br />________________Street Name___________ <br />State Zip <br />Ch__________jSJ ? C <br />Land Use Application # <br />phec-k# <br />Check if Billing Address El <br />Check if Billing Address D <br />Employee #: <br />Employee#: <br />Service Code: ^52 3 <br />Payment Date <br />1^2) <br />G c <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Date: (bCldft-12.0)2.3 <br />Date: /2^23 <br />P/E:./(^l <br />Received By: <br />Pel.______k/ A u L G <br />Gu t w t F <br />Street Name <br />Il <br />I Street Number <br />■ D t 5 T ■=> <br />Email <br />/ j < A 1/ g, j j g, t, e 4 f /'fcj| p1 a>..L i.l>“ <br />CONTRACTOR / SERVICE REQUESTOR <br />Phone # ext. <br />( ) 701 c I S' 6 <br />Fax# <br />( )___________________ <br />Email <br />o (e ! ol <br />_____f to <) <br />Owner I Operator <br />_____6 u i v d <br />Facility Name <br />________T u u i p A <br />Site Address i 3 <br />_____________________Street Number _ <br />Home or MAILING Address (If Different from Site Address) <br />7 I 3 Gu s N k E A r' 1' S> 7€ <br />City <br />_____A <br />Phone #1 ext- <br />< >-? 0 I $• Y <1 6 I $ G <br />Phone #2 ext. <br />( ) <br />Requestor <br />G. 1 v> <br />Business Name __ <br />______________TULlPAH <br />Home or Mailing Address <br />Cjp.GeHLf.AF <br />City <br />57£ B H* Il <br />___ State Zip . . <br />/A o q 11 t-j c A H 3 s G <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: <br />Property/Business Owner Operator / Manager <br />/f Applicant is not the Billin^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: Pltijh (yntbilc dec!) <br />Comments: