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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT CROS 303t cp <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Am(p ta82+ Li c)(ZOTS-+59e�) <br /> OWNER/OPERATOR CAn U) <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME C U T of �jI ( C�I �n n C <br /> SITE ADDRESS vSI v I (�1rI,J (�I JS� N bet Directiondo C�� ["S—jiat-bn <br /> Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I 1 IStreet Nlamel <br /> CITY \9 STZIP <br /> PH E# ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT FL7O� <br /> N CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORL <br /> q)y� CHECK If BILLING ADDRESS <br /> BUSINESS NAMECM , 1 -To s P � � 9(5��p E"T• <br /> IQHOME or MAILING ADDRESS . 1 FAX# <br /> � <br /> 1-�'o ( ) <br /> CITYSTATE /�- ZIP EMAIL <br /> \ - <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, T�and FEDERAL law <br /> APPLICANT'S SIGNATUR DATE: I d <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT isot 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. ( P <br /> TYPE OF SERVICE REQUESTED: Gran Of �(�;nerSltit CC Nr <br /> COMMENTS: <br /> 'Y 08 ?0 <br /> s <br /> N A,0 QUfN c ?y <br /> �Ty�pqM� <br /> � <br /> NT <br /> ACCEPTED BY: "Q,V 'I Cts M EMPLOYEE#: DATE: Cz <br /> ASSIGNED TO: -1,cu'k-d i c, EMPLOYEE#: DATE: <br /> Date Service Completed calf already Completed): SERVICE CODE: PIE: t(colz <br /> Fee Amount: )(a-2- .0(p Amount Paid I �2 Payment Date 8I 2�f <br /> Payment Type Invoice# 1 C61� F+L{L�n 822-- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> n <br /> 03/22/23 <br /> J <br />