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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST PiqoS4-11+-ILI <br />Type of Business or Property FACILITY ID # <br />f--A 0 9 4 <br />SERVICE REQUEST # <br />5R N3.8 1(6, zi+ <br />OWNER / OPERATOR , <br />1„. S AN (HE- CHECK if BILLING ADDRESS <br />DIME <br />FACILITY NAME E.. 1 Saire 50 <br />Street Number <br />SITE ADDRESS <br />Direction (, 4 r .21i Street Nalme City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />'SS c1A-v W'Stree; Name 5 <br />7 <br />- 3 i Street Number <br />CITY ( STATE ZIP <br />PHONE #1 Ex-r. <br />(30) <br />APN# LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / <br />L/ V ii Pc /0.5 5-1,11--'1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME c._ / Sa bfa so PHONE # <br />( 3/3 ) 6,0/ 75-tir <br />Ex-r. <br />HOME or MAILING ADDRESS, <br />3 1 1 5 5 ua. 1\k-0,56 5 —i <br />FAX # <br />( ) <br />Crrv S:r7ic STATE 64-- ZIP 9 5-2_0 5----. 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 Of activity <br />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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> <br />1 /1 6/ ZLf APPLICANT'S SI DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <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: -Tx- uc v.... 2..e CA. C il Vaki (..) n <br />COMMENTS: <br />ACCEPTED BY: G. '‘ c j ', F. EMPLOYEE #: B '.-- i DATE: I / 1 (0 Li <br />ASSIGNED TO: ;c , G 1). c ,,, 9._ EMPLOYEE #: •g DATE: I 1 1 I t )DI , <br />Date Service Completed (if already completed): SERVICE CODE: (t (4, p/E:k <br />Fee Amoun4 \ (0 2 Amount Paid oo Payment Date / <br />Payment Type Cx.e6t-24-1- Invoice # Check # i 7 z_i_c s---.2-4_2 Received By: <br />Title <br />SSR FORM (Golden Rod) END 48-02-025 <br />03/22/23