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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SROOST77 & <br />OWNER! OPERATOR <br />CHECK if BILLING A DDRESS <br />CAE \ 5 V \ A) A\ T)/1-t-V) _2- i 4, A <br />FACILITY NAME <br />Li--L NI 1-) 0 ,ii__-( \.4()L)9 <br />SITE ADDRESS <br />Street Number Direction <br />r-D i/1- <br />Street Name <br />64-c0Cg T°A) <br />City <br />c(SZ_I q <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />..\ <br />Street Number <br />I. ( <br />Street Name <br />CITY \-1 STATE ZIP <br />PHONE #1 EXT. <br />1-1 - k ck 6 C <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL <br />.\)1ALLO ti 0,4-) ‘-( H ObSt 6) c PM) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # EXT. <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 E VIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br />will be billed to me or my business as identified o 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, STAT nd EOERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: 8--L— <br /> <br />- r <br />PROPERTY! BUSINESS OWNER 0 OPER • • R / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <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 it is provided to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: C(Q`A-(0 I /444A1 <br />COMMENTS: A A PAYMENT <br />fi1ke61q6C 4rtt-C A- RECEIVED <br />FEB 29 2024 <br />SAN JOAQUIN COUNTY <br />CWIRONMENTAL I ACCEPTED BY: .r" /7 <br />/4-N l.4. / 2.-- EMPLOYEE #: HEALTH DEPAPMENT2/ 21 1 all <br />ASSIGNED TO: _r - ie,t ,' Z <br />EMPLOYEE #: DATE: ,212 _F 72 , <br />Date Service Completed (if already completed): SERVICE CODE: 0 Lo PIE <br />Fee Amount: g 0 A ke2o Amount Paid / 0 6, Payment Date <br /> <br />--//a—° <br />Payment Type \list), Invoice #C)3e11 <br />I q- I/ 7 t)) <br />'Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />vzostAIA