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kJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ?P,0SLl ucf <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 R®O S-�Co 03 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME -c-ctt C" <br /> SITE ADDRESS O C� / G Ll <br /> Street Number Direction Street Name f ` �� Zi ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) f I— I,�^ ) _Y7 <br /> Street Number 4 vStreet Name <br /> ITYo f, i x STS ZIP q <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 42 <br /> rPHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> oe,/'n 7,-11z CHECK if BILLING ADDRESS <br /> BUSINESS NAME `�' i• l%` PHONE# ExT• <br /> v <br /> HOME Or MAILING ADDRESSZ— (f ,n FAX# ) <br /> CITY �. Q STATE ZIPp 1 / / 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 wi h all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: C)/ I d o2 <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 t0 me or my <br /> representative. ` r <br /> TYPE OF SERVICE REQUESTED: �(� CUV1S L�\�(l 41 (Cunt v Gi &5kt"� ENr <br /> COMMENTS: iD <br /> 'AN 10 2024 <br /> SAN JOAQUIN <br /> ENVIRO CDUNTy <br /> H�7'H DE ART NT <br /> ACCEPTED BY:15� tCkno-' tut, EMPLOYEE#: DATE: (Dr 11(G1'Z�I <br /> ASSIGNED TO: y—a(i42aV1tNe L_ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: tc P/E: <br /> Fee Amount: 1�2. V'0 Amount Paid a Payment Date I I O 24 <br /> Payment Type CQe Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod)S <br /> 03/22/23 <br />