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-PR L01- CLO-9- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />0 I <br />SERVICE REQUEST <br />Type of Business or Property --- <br />-1)0C1-1-Ci Lk-CP---- <br />FACILITY ID # <br />-0), 00 -2_ 5--- 3 ii <br />SERVICE REQUEST # <br />ScZCIX2) b•-i- (09 4 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS P aA/14 r) S <br />FACILITY NAME r._---, EL <br />SITE ADDRESS <br />2 t4 4 0 Street Number Dion 414 a me aiCity Vo Code 2 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />P o /3 0 A / i / Z <br />Street Number Street Name <br />CITY STATE ZIP <br />Cia.44.17 q cz 3i <br />PHONE in Ext. <br />20 a/ .6 .2 // g0 <br />PN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR cet <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <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 accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Sejc\ (Jakjv DATE: - - <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is 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 proviNye or my <br />representative. <br />TYPE OF SERVICE REQUESTED: <br /> <br />. ICOV-iirrii <br />COMMENTS: n 7 <br />Sky ., ,,, u ' 2024 <br />,.v,4Qui ., <br />kt `ArVIRON Iv COUN EALry 0 ,,Wiv rA , 71' --p-A„si rmi-tvr <br />ACCEPTED BY: - l ' EMPLOYEE #: 07 - 0 -5 DATE: 9 / 9_ /TV <br />ASSIGNED TO: . EMPLOYEE #: __-? 6 DATE: <br />2/ .-)- / .2 <br />Date Service ConipleteEl}(if already completed): SERVICE CODE: 0 61 NE' A40 3 <br />Fee Amount: Si 1 Amount Paid/1,,2, 0--o Payment Date 7 2--q--- <br />Recei ed By:4717:7--- Payment Type • Invoice # Check # <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br /> <br />,6 <br />Title