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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FlIGZ18442. <br />SERVICE REQUEST # <br />SC(1)TE))-1 a \ <br />OWNER / OPERATOR• j . j CHECK if BILLING ADDRESS <br />vet /1-17:, htn <br />I FACILITY NAME <br />11.1 .5 4m.c.1 Pil e and (6n dliv;(,lheZ <br />SITE ADDRESS <br />U Street Number I Direction <br />Z zik) er <br />Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />9$-3 51 A4_v7:44,"6, 11,4, Street Number Street Name <br />CITY <br />y <br />STN'E <br />Sk2-h1-01 C-.)9 <br />ZIP <br />9.111Z, <br />PHONE #1 Err. <br />(2e)f ) (6'('?"7) .o/6 <br />APN# LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />54-01e_ 4-5 4 t4,,,,5),•-__ 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 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 /> <br />DATE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <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 prisilled to me or my: <br />representative. 414/f <br />"ECE/VE-- "ni TYPE OF SERVICE REQUESTED: C 1164 e 0 ( 0e,t) vt-cri 1,-- i p <br />COMMENTS: MAR 1 2 2024 <br />SAAI j°AQUW <br />14 ENVIRON c°uNry —EALThi DEIPENTAL ARTA4ENT <br />ACCEPTED BY: 6,,, i i...i. EMPLOYEE #: DATE: 311212,14 <br />ASSIGNED TO: rrari ci s co /2, EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ip(c, ( P/E: t 602, <br />Fee Amount: $ 1 (i, 2 Amount Paid 4 1 co , i..___ Payment Date 112.12.1f, <br />Payment Type Oevice Invoice # "Cinc/1--, ki--9•9 a_cb l-. Received By: ati -7-6- <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />"PR° S212,3 <br />-^