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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />04 <br />FACILITY ID # /4 SERVICE REQUEST # <br />OWNER! OPERATOR <br />‘-` CHECK if BILLING ADDRESS V-,rA j e'\ u s MI he 7 k_sr (-JO <br />FACILITY NAME ck( y <br /> <br />SITE ADDRESS A U->(k y <br />-2 (ICC Ill - ( ctretdttlurr er Direction -4F-: .---\ 0 li d , <br />Still& Name <br />S-r f 0 Cli-k\ City <br />20S q S. <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />2_7 2:c) B I acii_lowd CA- Street Number Street Name <br />CrrY ( STATE ZIP <br />t-C) (--V 6r\ (... /-\ ci 5_2_) U <br />PHONE #1 Ma. <br />22- Co3 0 t <br />APN # LAND USE APPLICATION # <br />PHONE #2 En. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR '11-1/("." 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 />c -- i <br />' J <br />1 S G \ 0--Orn I it7 JO ir/d 0 DATE: 2 / 2 c / 2 Ai APPLICANT'S SIGNATURE: <br />i <br />PROPERTY! BUSINESS OWNEM OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: r 74 nye A . <br />ReCe nir c---- COMMENTS: itfe0 <br />itk V, F CO /k-Y -cr).-, <br />FE8 9 <br />4 u 2024 <br />8.41v,JoAclum, <br />lizivvmoiviiEcctihrry TH DE.,,44 ,,irAL <br />ACCEPTED BY: . EMPLOYEE #: 2 j ,.7) DATE: '24 241+ <br />ASSIGNED TO: <br />LA-4) frk,4-4-0-- <br />EMPLOYEE #: 67 g2:::g DATE: ZiO 2_471. <br />1-1/ Date Service Completed (if already completed): <br />t <br />SERVICE CODE: b (e ( E: 1 bp3 <br />Fee Amount: 4 1 ,, Amount Paid ,,. ( u 2 . _- Payment Date <br />Payment Type .,i, got Invoice # _Chre1.41 1 -+( j-, 3-325-b Received By1)07-1 <br />END 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />Title <br />171205,- 22_cl 0 S