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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />T pe of Business or Property <br />1 Tr <br />FACILITY ID # <br />1--AONsq .4-t1 <br />SERVICE REQUEST # <br />sa oorgq Gs oi <br />OWNER I OPEAATOR , CHECK if <br />(-1 ry Da rdf ,s -f>_k_ 4 ri ki no BILLING ADDRESS <br />FACILITY NAM <br />el-scl....f:ct El 4/2-t-cc-c-, <br />SITE ADDRESS <br />()I 6 Street Number Direction HC41/ I rile r'Stiedaime <br />F "fe--41sG4k / C CA <br />City <br />752cx-1 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />rty 114.--ACICZ. <br />BUSINESS NAME r, Ta <br /> IlryLocit / <br />,, 4, r ligPILI_E5tt <br />(Z- 1)2 /q —2'03- <br />EXT. <br />picomE or MAILING ADDRESS <br />0/90 1.1,e/C-il l''r <br />FAx # <br />( ) <br />Cirv cite r po (el STATE Cci <br />ZIP q.5- 3A'. <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 <br />or activity 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 />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OwNERD OPERATOR / MANAGER 0 OTHER AUTHORIZED AGEN1 <br /> <br />IJAPPLICANT 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and riAymEtwr it is <br />provided to me or my representative. <br />tg.CLrIGI V L.LJ <br />TYPE OF SERVICE REQUESTED: 4-1C)Ci Fto.. v.c1714 cfc____ <br />COMMENTS: DEC 0 2 2021— <br />SAN JOAQUIN COUNT( <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED By: 1 yv\..... EMPLOYEE #: DATE: 12, 2, 2.,1 <br />ASSIGNED TO: ryli F- EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: ._z3 , PI E: <br />Fee Amount: c 1.4 i.c , -4 1 Amount Paid Li ' - Payment Date I 2_,/ 2-- ( ---7„, 2— ( <br />Payment Type \] i/G A____, Invoice # _Check # : 3 s-y 3 1 S-----Received By: frie7 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />N. 5 2-3 (-0 3