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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FA00 (23115 <br />SERVICE REQUEST # <br />sRecn7(pci (I) <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS VvA\ Vr,\ ‘66? l r 7 ( <br />FACILITY NAME . . . <br />r1,1-i)) 12c_ VP cc__ --k. l:-,1:-•\ S <br />SITE ADDRESS <br />Street Number I Direction 611/4-1 eS0 Street Name 5T- I <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) tif lc Q_uyAt cicst- -1-) . Street Number Street Name <br />CITY 1 _ , STATE ZIP <br />PHONE #1 Exr. <br />(729- -77 - LI L 1, I <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Saraf•42- as abo4 e CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # EXT. <br />( ) <br />HorviE or MAILING ADDRESS 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 FEDE WS. <br />INF APPLICANT'S SIGNATURE: DATE: 7 — <br /> <br />PROPERTY! BUSINESS OWNER El OPERATOR / MANA ER II/ OTHER AUTHORIZED AGENT El ANA ("\ZA Pc,,s 17),k <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 proviclip4pe Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: CIA CLA ot °t)ne r s h's <br />COMMENTS: rk6) y <br />0? <br />2024 &Akio <br />H8fAtfri:y1Qu/N <br />COML V lac& -co r CO nSa Ra--60v1 1 nSpeck- iCon . --(7-Hoop,A,c07.4u,v4, <br />Piviir, 4 <br />ACCEPTED BY: 5. 5,111,00...11n EMPLOYEE #: DATE: 2 ._J ... A4 <br />ASSIGNED TO: V . p edreiz a EMPLOYEE #: DATE: 2 _ 7_ a, 4 <br />Date Service Completed (if already completed): SERVICE CODE: 0 (0 ( P / E: iuoa <br />By:/—Nr <br />Fee Amount: $ 1(0 2, or Amount Paid /6 2, .(.1:0 Payment Date <br />Received Payment Type (24k.e) Invoice # Check # 1 7 67 i 32_5-22- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />ot <br />vir <br />?g091139i-{