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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST -F03LoOS°1 <br />Type of Business or Property FACILITY ID # <br />frf)0001 '-5-19 <br />SERVICE REQUEST # <br />SRCIT7V50 <br />OWNER! OPERATOR Pm-in6/2 >Obey P01/21c I P CHECK if BILLING ADDRESS <br />FACILITY NAME <br />abbeg Porote 411-tg <br />SITE ADDRESS ) 0 /10 <br />Street Number Direction <br />-r -LieL_ L_N <br />Street Name <br />,s/-7ciaz;r\J <br />City <br />- C19 <br /> <br />Zip Code <br />HOME or MAILIN ADDRESS. (If Different from Site Address) rr <br />Street Number Street Name <br />CITY <br />,_S:17 0(44—Olj <br />ST#TA <br />Cl/ 4PS 7 ") <br />PHONE #1 , L-I-7q- 38;z_ <br />IT• APN # LAND USE APPLICATION # <br />PITT ch elq 9 __z42_0 __7_E)cr. <br />t* / Of <br />EMAIL <br />Co y,el 604-,77701 • C-zin-7 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />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 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: <br /> <br />DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 infor ation to the • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid Aleiar my <br />representative. /1' , <br />TYPE OF SERVICE REQUESTED: czvn site/oz./7(72-i . <br />COMMENTS: S AMR <br />A1 A , r Jo A c 2024 <br />'4\17.1148°8v c 11 441S/v 79:414-/Nry <br />'''IR 74,7div 7. <br />ACCEPTED BY: L„t et L 4;1__ EMPLOYEE #: CiY1 S DATE:2 <br />L/ <br />ASSIGNED TO: A f (4L4.? EMPLOYEE #: e .0 - - - DATE:, _ (9-- <br />Date Service Completed (if already completed): SERVICE CODE: 6 oi IE: <br />Fee Amount: k 0?--- Amount Paid / d------ Payment Date <br />Payment Type c)/z/Nr Invoice # Check # /-7g5275,7D Received By: <br />Gtn4/r76.10-7.44-1785).7,-5?0 SR FORM (Golden Rod) END 48-02-025 <br />03/22/23