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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop" FACILITY ID# SERVICE REQUEST+f <br /> 0020-n4 S9-W8 +-+(0Lr <br /> OWNER I OPERATOR pfcK If ElLuw,ADORsss❑ <br /> FAciuTY NAME <br /> SITE ADDRESS 6k- <br /> StreetNurrber Directbn streetltane <br /> z code <br /> HOME Or MAMG ADDRESS (if Different from Site Address) S-- � rN e Vim. Q 6i l v;t <br /> saver Number street Harm <br /> CITY STATE Zip <br /> PHONE Yt EXT. APN 9 LAND USE APPLICATION# <br /> Lo u(.� - L- I } <br /> PHONE#2 EXT. Em AIL EKGS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C)-ecx if BILLING ADDRESS❑ <br /> BUSINESS NAME E ExT <br /> V t Ittil I h� �"-1 I <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 /> 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 /> APPLICANTS SIGNATURE: � �' �/))'12(- �- - DATE: Ca I Z <br /> PROPERTY f BUSINESS OWNER 0' OPERATOR f MANAGER ❑ OTHER AUTHOR®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 environmentaVsde assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br /> representative Pc <br /> TYPE OF SERVICE REQUESTED: ---- D <br /> COMMENTS: C FEB 26 <br /> SAE JOA QU/N CO <br /> r HEALTH pE oENT, 4 NTY <br /> M NT <br /> ACCEPTED BY: e-7i i EMPLOYEE#: fj�YjB DATE- (02IZ(o12q <br /> ASSIGNED TO: EMPLOYEE#: F) 8 DATE: m7I2GIZ4 <br /> Date Service Completed (if already completed): $t NNE CODE: m(ol P i E:;(O( Z <br /> Fee Amount: $/511Amount Paid eo Payment Date <br /> Payment Type ` Invoice# Check# ��3 4 /53 7 Rec ived By: <br /> EHD 4&112-025 SR FORM(Golden Rod) <br /> 03/22/23°° <br /> r <br />