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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br />DATE: <br />PER OR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER I OPRATO7 <br />CHECK <br />if BILLING ADDRESS f 1 l 1 0'5 e orI-es , <br />FACILITY NAME ,/ \ . 74-accv7i-gibe-(--P-2 DS 7-- f e a e_ <br />SITE ADDR74 3VA° Street Number Direction Street Name 77 City7 7e)6( Zip Code <br />H9ME or MAIVIG AD,DRESIf Different frryte Address) <br />151,C)elit if Street Number Street Name <br />CITY ••"---- ST(A-72. zip75-3 ,/ <br />PHONE #1 <br /> <br />EXT. <br />( )6(/) t /f 6 / 5-'° <br />APN # LAND USE APPLICATION # <br />PHONE #2 <br />73 <br />0 EXT. EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR . <br />--7a nie 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 applical and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE FEDERAL laws. <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 Of my <br />representative. <br />. II /M- <br />TYPE OF SERVICE REQUESTED: mog/L5 le-Deb —7—/2 61 /2_ 5 -(. ReCivii%17. <br />ATO <br />COMMENTS: <br />°EC 0 8 202 <br />3 8.4 1v J0,10 <br />AlviRou'''' cou nek.7 .8 NA, evr Ivry <br />DEpAii ,...,AL , wee <br />ACCEPTED BY: e ,, /14 61 P._,L.9 EMPLOYEE #: DATE: <br />ASSIGNED TO: (1,7 IT /746 /yE A-;L7 /71/A /7 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: /157/23 9K/ <br />Fee Amount: 17 I il 2_ Amount Paid L ..- Payment Date (1 I ei 2 <br />Payment Type riouicp Invoice # _Cilrect(critior 3 I-42 Isa)-44 Received By: 407d) <br />END 48-02-025 SR FORM (Golden Ro <br />03/22/23 <br />N'osi-M53