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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T--A®Om (P 33 SR(2)0q -7736 <br /> OWNER/OPERATOR e <br /> C k V 1 y� c � i C k I nit t n CHECK If BILLING ADDRESS <br /> FACILITY NAME �l(� •--1 <br /> SITE ADDRESS 5 3 'a N ' �/� a 1 M a yl--e c d 9 5 3 3(o <br /> Street Number Dir¢ction 1_ \ Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) +`'_) 1r/��� Flann-eOl <br /> Street Nu}nber Street Name <br /> CITY Ma►i teat STATE CA ZIP (arli 3�f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (44 t7O fTJ> <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (4& Q-1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S <br /> O•V CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# Ex-r. <br /> K-1 -4q5 <br /> l�i �1� 2►'1 <br /> HOME or MAILING ADDRESS FAX# <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 /> 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 Fi ERAL S. <br /> APPLICANT'S SIGNATURE: DATE:.2 r2J 6-02 <br /> PROPERTY/BUSINESS OWNER OPERATOR ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLIN ARTY,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 io the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time It Is pro <br /> representative. L' <br /> TYPE OF SERVICE REQUESTED: l� <br /> COMMENTS: SAN JOAQU <br /> 7 <br /> RICOU,Afe1Y <br /> mM NT <br /> ACCEPTED BY: ^ EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: _ O _c')- <br /> Date Service Completed (if already co&leted): SERVICE CODE: PIE: I co <br /> rl <br /> Fee Amount: l (�a Amount Paid 2 Payment Date 2I2O�2 <br /> Payment Type /) d Invoice# Ct>� -tU—T::f21 eceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> SSS 22� <br />