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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />V( f <br />FACILITY ID # v SERVICE REQUEST # <br />`..,.(Zoo8 354 3 <br />OWNER / OPERATOR <br />1\ CHECK if BILLING ADDRESS GI dello a /C6-A' r 1 Z- s Va LC f <br />fACILITY NAME el n <br />LA co EEEc:i To n De_ 7e-1-4 y <br />SITE ADDRESS <br />t ss L4ettr 5 Direction CO. S eS Street Name ircrico oil 9.Sa.--, <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />S1404A/6 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Ex-r. <br />HOME or MAILING ADDRESS FAx# <br />( 1 <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 accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FE ER 111 • r <br />A/VP!. I." ":* <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 Of my <br />PA <br />- TYPE OF SERVICE REQUESTED: Af-- F , <br />,.. --.4...r 't, ..e.,,,_ (Lii , Rcceiv4 <br />COMMENTS: <br />CA:C 19 20' 4 <br />SAN JOAQu <br />ENVIROAIN coo\ <br />HEALTH DEpAIAPTAL -TWA <br />ACCEPTED BY: < EMPLOYEE #: (7"4 c DATE: (2.—(LL 23 <br />ASSIGNED TO: 1_ i / <br />( <br />AP-- vie/ <br />EMPLOYEE #: CI 3 y DATE: 24 , 1 , <br />Date Service Completed (if already completed): SERVICE CODE: ,2.....3 <br />I) <br /> P /E: . ,A) <br />Fee Amount: 0 Wo Amount Paid 4 LEIB 4,-- Payment Date 1 2 R ci .7 <br />Payment Type Lco\AA_ Invoice # Check # Received By <br />APPLICANT'S SIGNATURE: DATdc'a - ?- ,()3 <br />representative. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />P‘cs(-1g ,01