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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT�P"' <br /> SERVICE REQUEST cs.�,ef`C- <br /> Type <br /> of Business or Property Dgj4o j! lei S5 FACILITY ID# SERVICE REQUEST# <br /> /x// A4 r� sruR,9�-� FA� 0018504 SRoog -7 5S4 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> F F IpA/ V <br /> FACILITY NAME T HA a dR 6-X P 1,L SS <br /> SITE ADDRESS l�ccYYl J0 0 � C/F-53 3 a <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 0-15 —m l4 G Street Number Street Name <br /> CITY mA/It T Oc--7 C✓1 STATE ZIP <br /> PHONE#1 1 ExT. APN# LAND USE APPLICATION# <br /> (Ue7) --7-71 17 33 <br /> PHONF#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �] CHECK If BILLING ADDRESS <br /> BUSINESS NAME l/ PHONE# ExT. <br /> ( <br /> HOME or MAILING ADDRESS FAX# <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 /> 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. a <br /> APPLICANT'S SIGNATURE: cz_ ��: <br /> DATE: I ✓ D <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: Ca RECEIVED <br /> COMMENTS: JAN 0 3 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 243 DATE: <br /> r <br /> ASSIGNED TO: / � EMPLOYEE#: J DATE: �• <br /> Date Service Completed (if(already completed): SERVICE ODE: C 1 E: <br /> Fee Amount: Amount Paid a Payment Date 3 <br /> Payment Type Invoice# C ck# �0y4L/ I Received By: AV <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 (�O��W09 c <br />