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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property 1 <br />aci4 .71- Ch -) <br />FACILITY ID # SERVICE REQUEST # <br />RØ®5 (o S <br />OWNER / OPERA-fp/4 _ CHECK if BILLING ADDRESS —7m '.e ei 7/\ <br />FACILITY NAME 0 4,/a.....e, we 3.." <br />s5,E ADDRESS <br />/9675 Street Number Direction i rp Orl ........4ete6im 7.5-zwie/7 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />(9•1-1.12 .-g.s 2, <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />-5D ligY'--- D9.7 5— <br />EMAIL <br />/1/ Ikte.1 t=2 iti V ('-461.1/1464_//Z-C-i <br />BOS DISTRICT <br />L.- <br />LOCATION CODE <br />CONTRACTOR&SERV4CE tREQUESTOR <br />REQUESTOR i j /4 CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME 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 he work be peIjmed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDER WS. <br />APPLICANT'S SIGNATURE: DATE: /2-- 2 2-4t3 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MA AGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <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 assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itil4f rovided to me or my <br />representative. AYMENT <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />COMMENTS: DEL z 7 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ( -Iva et; I 0 <br />EMPLOYEE #: 0 4(s7 DATE: / R ... 7 _07 3 <br />ASSIGNED TO: C e <br />EMPLOYEE #: q v 1 2 DATE: i ,g _ 3. 7 _ 3 <br />Date Service Completed (if already completed): SERVICE CODE: :r-.) ( ( ., 0 PIE: <br />Fee Amount: I 6 2. Amount Paid Payment ate i 2_ I 21_125 <br />Payment Type Ccof20 Invoice # -Gcleal 1 \ 1-6C1-4-t) Received By: 6,W -77r <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br /> <br />PRo5I-1819-1