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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />T.----- 0 a CN\ --\--V C_Al <br />..;irt) <br />FACILITY ID # <br />zo:ko 0 <br />SERVICE REQUEST # <br />Sc-00 (3 —\ Le. ULD <br />OWNER PERATOR <br />CHECK if BILLING ADDRESS <br /> <br />CI - /S/M4 /0 /r <br />FACILITY N E <br />()Pry <br />SITE ADDRESS 7-3 " Li <br />Street Number Direction <br />5 ( 6 lifoirlick .54- <br />Street Name <br />.5 /0( /-',. /0)i <br />City <br />9 5 (6) <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) (,) LA <br />Street Number <br />ai W r 5 0 (-) ( Street Name <br />CITY STATE <br />(A <br />ZIP q 6 z /6 <br />PHONE #1 EXT. <br />) l i_ (e09 z q_ 0 56 APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING <br />EN / <br />ADDRESS ..... <br />BUSINESS NAME \-- Ncluo PHONE # <br />(2-O\'2-\ - <br />EXT. <br />HOME or MAILING ADDRESS p\---J-(2_, FAX # <br />( ) <br />CITY <br />1\\("N <br />STATE ., ZIP 0\c,--.3'. EMAIL <br /> DATE: (/O / / 7 0( y <br />PROPERTY / BUSINESS OWNER 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 provided to me Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: <br /> <br />rl'e IVI* <br />COMMENTS: 4,4 p <br />.44 Ai <br />IV Z 2 2024 SAN Jo <br />ilEf411144r5QUIAI CO <br />4, <br />1 \ ACCEPTED BY: EMPLOYEE #: (.0 2L7 DATE: ( 1721 * 0 001- <br />ASSIGNED TO: EMPLOYEE #: " DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 1 PI <br />Fee Amount: .(. \u2 /2_, Amount Paid jpcp 2 ,--- Payment Date 1/2 4 zi..± <br />Payment Type Invoice # -C-PteZ1*: 1-4.2._15e3 Received By: cAu-n, <br />?rko5 1V-c? s <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: <br />Title <br />EHD 48-02-025 <br />SR FORM (Golden Rod) 03/22/23 <br />-Peosu1i33±