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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> roll �PY !ICe � aa��� Uo � 2u� �?C�,Q;�, <br /> OWNER/ PERATOR <br /> C r CHECK if BILLING ADDRESS <br /> FACILITY NAME `�� /ore <br /> 1� J J��� n <br /> SrrE ADD S `J / 1�C�7 v 3 <br /> Street Number Dion I-la'r (/C�Et - Rarh ��C'i �Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> cslD) 333-8ggl q <br /> PHQ�1�$� _ EXT. EMAI BCIS DISTRICT LOCATION CODE <br /> s '/7J �o loris <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU S 6 6�e � <br /> CHECK if BILLING ADDRESS VY <br /> BUSINE A � oreJ iia ei �L S / ��.>� 'l <br /> 9OME res,,riiv�j PS� 33 3- 8 7 q Ex-r.. <br /> H �"l r��I��RE�GLIr FAx# <br /> CITY) QA rb elT ZIP �jS 3�/1 EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business Cowner, 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: 6-71-Ibm /7) C O " DATE: 2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ ER AUTHORIZED AGENT ❑ <br /> /(APPLICANT IS not the BILLING PARTY,proof Of authorization to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,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 its' rovided to me or my <br /> representative. �NJ <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: U /� <br /> 4 R <br /> O <br /> S4 At� S <br /> 024Ru/NNyoPQR�0- �' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: e EMPLOYEE#: DATE: 3 �, 2 u <br /> Date Service Completed (if already completed): SERVICE CODE: tD b P/E: ' O7 <br /> Fee Amount: 1 b2 _ Amount Paid 1 he <br /> 1� 2 _ Payment Date 3, b, 2 Y <br /> Payment Type C Invoice# Check# ' Received By: <br /> EHD 025 <br /> 03/22/23/23 SR FORM(Golden Rod) <br />