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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR M a � � <br /> 1 S d'j 11� G� C2 � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �n (�O C O ei t C) l <br /> SITE ADDRESS �$ 0 <br /> Street Number Direction vl Street Name 1—v Ci W t Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) D"s i/ 2 <br /> / 2 S A,• �,�z/�/1 S T <br /> Street Number Street Name <br /> CITY1 V C,`t STATE �±n ZIP Z- U <br /> lP #1 E-r. APN# LAND USE APPLICATION# _1 <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> M G fJ 1 h Po 1 `vy ` Fol, (A-/ �) CHECK If BILLING ADDRESS <br /> BUSINESS NAME '�`—t^/r1 C O S C p nJp 1 � ��N r i j Exr. <br /> HOME Or MAILING ADDRESS i tom'1 gLo < 1/ZFAX# y <br /> C l�1ta�-VI ,t ( ) <br /> CITY LVCI ` STATE CA ZIP pt S-2 L.1 L) 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: -,(�� �G�f,�� DATE: <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 provided to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AIZIA <br /> 2 <br /> ��QUliy �.� <br /> �CryoEp ��. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: '2 <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: c I Amount Paid Payment Date 12(—::H 2 <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 PRO 15 I r n LAW/) <br />