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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST I(Z 05L 032 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (L ---�; \ i 0, ( V--' eA- (1 ;�J �V-oo61�)'& <br /> OWNER/OPERATOR <br /> �/I kA <br /> O I r �,'����{� 9 tAG / { / n f (�- CHECK If BILLING ADDRESS <br /> Q FACILITY NAME/\ t6 1r igy 1 U lYI C �7{'�t J C1�1 !\N� au;V I t- 'L /l El�-t-�l �I"E <br /> SITE ADDRESS ?j/�j W� T1'"� DC7 �?j1,lo <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J/% 4 / L�'� <br /> Street Number Street Name <br /> CITY .�n� STATE �+ ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M� CHECK If BILLING ADESS <br /> BUSINESS NAME (� HONE# Ems' <br /> C?� CnGv c7. C- ( ) 3 <br /> HOME or MAILING ADDRESS 221 FAX# <br /> CITY /l C STATE A.- ZIP <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 <br /> activity 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 FEDERAL laws. <br /> X APPLICANT'S SIGNATURF�: DATE: <br /> PROPERTY/BUSINESS OWNER E OP R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: C ,' �\ (\5 c�- RECEIVED <br /> COMMENTS: APR 0 1 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �� Y"1�c�r <br /> EMPLOYEE#: 5� DATE: 3- Zy <br /> ASSIGNED TO: ��le EMPLOYEE#: �8 DATE: 3• 20• Z� <br /> Date Service Completed (If already completed): SERVICE CODE: j f /E: `b Z <br /> Fee Amount: _- Amount Paid Payment Date <br /> Payment Type 1 b2- — Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />