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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4A 002 Z -3� -- <br /> a 2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> • <br /> �o r'�,n I: A Z6)1 hc:4,:7A S L.LC <br /> FACILITY NAME <br /> {-1"- \)C <br /> SITE ADDRESS <br /> `� .nt�rncl�l Lh SAo� .n-+oma qS <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3 Gl I ( ` ` D ( I C� <br /> l Street Number v Street Name <br /> CITY STATE c4 ZIP <br /> PHONE#1 xT. APN# LAND USE APPLICATION# <br /> (m _ l <br /> ) 4 <br /> (Ply�— S Z S <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 3`�� ' iJti,! C 4 ( ) <br /> CITY C y�n STATE G /� ZIP n j2 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 /> 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: DATE: 02 IO6120214 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 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 pr0j�" �/ a or my <br /> representative. L <br /> TYPE OF SERVICE REQUESTED: �(� <br /> COMMENTS: 6 <br /> 4"Jow <br /> Th <br /> "roIIVi T Jill <br /> ACCEPTED BY: EMPLOYEE#: DATE: /2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: (— <br /> Date Service Completed (if already completed): SERVICE CODE: ' P 1 E: 1W2 <br /> Fee Amount: At ((Q 2— Amount Paid I/ �1 Payment Date a <br /> lX Ol, <br /> Payment Type Invoice# �r�ck# O�L�/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />