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DATE: <br />OPERATOR OPERATOR / ANAGER 0 OTHER AUTHORIZED AGENT 0 <br />APPLICANT'S SIGNATURE 3 Zoz`( <br />PROPERTY! BUSINESS OWNE <br />SR FORM (Golden Rod) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FAcmo11g5 <br />SERVICE REQUEST # <br />SROCO g -7 5 '5N <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />ii\-Ck 10 OCANici 0 \I( Cick Ca.tcckmo <br />FACILITY NAME r 1 <br />SITE ADDRESS Ii Ø <br />Street Number Direction <br />kJ IA aier too -Ra <br />Street Name <br />sivc g+ty.,_ <br />City <br />c15,2o5 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1(5 Z-Z W kG'C IA S i. Street Number Street Name <br />CITY STATE ZIP <br />CA 9S rc3 <br />PHONE #1 Err. APN # <br />1 41- 150 -01 <br />LAND USE APPLICATION # <br />w4^ PHONE #2 Err. <br />(IL5 ) 3 13 — g ( 9 2_ <br />EMAIL •'' <br />eAvy\Q c ma cc 0 r-R 0 rrkc-vd <br />BOS DISTRICT <br />0131 <br />LOCATION CODE <br />0i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />r:411141 ; <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <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 />I also certify that I have prepared this application and that the work to be performed will be done in ccordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard, STATE and FEDERAL laws. <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%rfnation to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prow Lae" or my <br />representative. "zCi,1 Air ft. vrei) <br />TYPE OF SERVICE REQUESTED: C....6-1k_S,Lit .,- /4 Ast 0 <br />1 <br />, <br />COMMENTS: SAN .fr, j 2024 <br />ZiVvrIQU/N kiEk. ROA* COUN <br />rii0Ep Ovzii. rl, <br />Ayr <br />ACCEPTED BY: ...-- EMPLOYEE #: fil 2.4 --s DATE: I, s, I 24 <br />A k <br />ASSIGNED TO: ieticco-t— EMPLOYEE #: CN2_ W DATE: t .3 . <br />Date Service Compl ted (if already completed): SERVICE CODE: G f PI/E: 1 / is .--, <br />V O / <br />Fee Amount: Amount Paid 4A cc2...-- Payment Date <br /> <br />Payment Type ectaL <br />tE2- <br />Invoice # Check # Received By: W5-771. <br />EHD 48-02-025 <br />03/22/23