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SAN JOAQIJIN COUN'ry ENVIRONIMENT'AL IIEALT]i DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> \S.(�S \V` (1' CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 C T <br /> S�1G �t <br /> SITE ADDRESS ( i 'Ct �''\�C_C'1�'1 (f4 Y )�C� Ul 1 C)5 Z-C"` <br /> Street Number Diroetlon Slreet Name CIt ZI Cock <br /> HOME or(NAILING ADDRESS (if Different from Site Address) <br /> Stroci Num6or Strout Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATIDN CODE <br /> t�i4 ) 8C 3 C`l3' <br /> CONTIU&TOR/ SERVICE REQUESTOR <br /> REQUESTOR nl 1 ui , <br /> CHECItifBILLINGAODRESS� <br /> BUSINESSNAME PHONE# Exr. <br /> � /1S <br /> &7 ) ,963 6rls` <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> 13IL1ING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific LNv[RO�I4ANTAt.I-Ica1.TH DGPAwn-ot-,N-I'hourly charges associated with this project <br /> or activity 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 JOAOUIN <br /> COUN'rY Ordinance Codes,Sten dards,,STATF,an 'EDFR Llaw.- <br /> APPLICANT'SSIGNATURI?: UATG: <br /> PROPERTY/BUSINESS OWNER OPER:\TOR/MANAGEA ❑ OTnP;R Atrrl101UZED Ar:Eh"I-❑ <br /> rAPPL(GINI''is not the LILLtyc,PARTY,proof of rmthrrt izulinn to sign is required Tirle <br /> AUTHOTLI7,ATION TO RE1.,F,ASE INFOYZMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, aeoteclutical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY F,NVIRONNIENTAL TICAL'rH DFPAICrn4ENT aS SOOn as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ?. ` C.. PAYME REef-W_T <br /> COMMENTS: <br /> FEB 2 1 2024 <br /> SANJOAQUINC 1NIY <br /> ENVIRONMENT I. <br /> HEALTH DEPART EN1 <br /> ACCEPTED BY: `— EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complet d (if already completed): SERVICE CODE: J �/ 1 E D <br /> Fee Amount: Amount Paid / Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> El IDREV SED 11/1712003 <br /> 125 ��,^ / � � P /7/�� J J I SR FORM(Golden Rod) <br /> REVISED 1 111 712 00 3 ( .�' / lT/ T'`" / IG <br /> (( 11 PRoI �o D q—+�o <br />