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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 'l FACILITY ID# SERVICE REQUEST C'— <br /> FA 0 �I-3-S �� Yv —' , <br /> OWNER/OPERATOR t!� <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME "Y 1 Li H 31 L4 <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 'S 55'-1 <br /> Street Number Street Name <br /> CITY $TATE/-, h ZIP q <br /> PHONE#1 `J Exr• APN# LAND USE APPLICATION# S w <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I ��11 (n J V�„ /�, �il CHECK If BILLING ADDRESS <br /> BUSINESS NAMEgo�C P I 5e-1 <br /> HOME or MAILING ADDRESS 31; <br /> S LI j L,Dir n S FAX# `+ <br /> CITY �� 1 -c STATE (+/A ZIP Gj -J 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 /> 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: ��� A 77, 0C-k� DATE: 12 - 2-7 -25 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 pLovided to me or my <br /> representative. 14 <br /> TYPE OF SERVICE REQUESTED: T wV V eh Al L oS <br /> COMMENTS: n�A AV p 0 (` � ®EC 2720 <br /> 8AN jo 23 <br /> v 1 l�r L (al,( U t1 a AQUI <br /> HEgNHOOPAR ou <br /> AL <br /> Ekr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already Completed): SERVICE CODE: j f P I E: <br /> Fee Amount:141-1'r <br /> 1 0 2 1, Amount Pal 16'206 Payment Date <br /> Payment Type i Invoice# Check# j �� R eiv d By: <br /> EHD 48-02-025 I SR FORM(Golden Rod) <br /> 03/22/23 C� <br />