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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />S1/4 t COP-(Pg 2- <br />OWNER / OPERATOR <br />V--O /1 C. CHECK if BILLING ADDRESS <br />FACILITY NAME <br />\-,)e5‘ -Pt Ot (VVe S <br />SITE ADDRESS I ;() 1 <br />Street Number Direction <br />3a c 0L /1/WIA)-1) Si- <br />Street Name <br />L ad•( <br />City <br />g 5 2-4 () <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) \ -0 2,3 --1 <br />Street Number Street Name <br />CITY <br />°-AY4 STATE a4 ZIP <br /> <br />PHONE #1 EXT. <br />(2CA V1 2'--g lg 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR K AnwAlii.i--- Wit,vu( CHECK if BILLING ADDRESS <br />BUSINESS NAME 0/1:, <br />t•->11 r-ke 5 poplrAtt) XT. go ,i q t. <br />HOME or MAILING ADDRESS <br />1 0 /- 3-1-- -7-k- el() L-y--\ FAX # <br />( ) <br />cITY G:1/1"--1-) STATE CA ZIP °KZ' Z <br />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, T E and FEDERAL laws. <br />APPLICANT'S SIGNATURE: .)c <br />PROPERTY / BUSINESS OWNER 0 OPERATGRTMANAGER 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 provipAlfaine or my' <br />representative. I E N <br />TYPE OF SERVICE REQUESTED: -AIIDG \itc 114 0a/03-4k-pk-A------- <br />ri, c (;Eive,0 <br />COMMENTS: <br />i'S -0-) — (0(7 szki 0 2 2024 ---.. J <br />°AQUIN COIJArry ENVIRONm "EALTHDEp ARTNENT <br />ACCEPTED BYcikl---/ EMPLOYEE #: DATE: ... 2 2_L\ <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: t_ <br />Fee Amount: 47 wy2,.....- Amount Paid I(C) .---- Payment Date -2: 2_ 21+ <br />Payment Type catop Invoice # ...CpZ4f, t ).-1.2 Le-7421 4 Received By: eif A;72c <br />DATE: <br />Title <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />PRO9-h3Col