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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST 0 sui goio <br />Type of Business or Property <br />\\-80\- a c5-_,(---+ <br />FACILITY ID # <br />, <br />SERVICE REQUEST # <br />....., <br />OWNER / OPER OR <br />CHECK <br />C\-c- <br /> <br />ç -M-S\(10-._ (V)--0\0kr\C\ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME (-3 1 <br />K \ (45 .9J.3 <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />"2- S Z g S C\,C`t--- \ Ci.o W C'i 1\Tr Street Number Street Name <br />CITY STATE ZIP <br />C r- 0 C-i-c)(-N LAA <br />PHONE #1 Err. <br />(7S-1) 33 t - o L+ S Lf" <br />APN # LAND USE APPLICATION # <br />PHONE f3 Err. <br />( igl) 4C " 2,0 Cb- - <br />EMAIL, <br />y_ot l 1-}.- Lc-U>. (-An k oo co tv, <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME NAME l ‘ PHONE # Ex-r. <br />HOME or MAILING ADDRESS <br />k S. <br />\ . 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: cvA\c„ DATE: ta-1 <br /> <br />PROPERTY! BUSINESS OWNER ra OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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 assessmen nformation to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pro <br />representative. <br /> N7- <br />or my <br />TYPE OF SERVICE REQUESTED: <br />JAN COMMENTS: <br />!ALA \t pocd <br />12 2024 <br />sitv JoAQ <br />E'vviRo u''' co HEALTH uN D:pmeivrALTY AR rivElin. <br />ACCEPTED BY: t.../0 LA (-0 EMPLOYEE #: DATE: l l 2i2j ip <br />ASSIGNED TO: V I (701 EMPLOYEE #: DATE: / 1.2 <br />Date Service Completed (if already completed): SERVICE CODE: ()C/ PIE: L/Loo3 <br />Fee Amount: f "00 Amount Paid W Payment Date Vi2/2_ <br />Payment Type i, , Invoice # Check # 1-7 2-1-'7 6/cy 2._a-s— Received Byyk <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23