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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br />DATE: Li 93 <br />ANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />i-A002-34ilo <br />SERVICE REQUEST # <br />sw)a)B-- 42s <br />OWNER / OPERATOR <br />l ic) GaccA CHECK if BILLING ADDRESS <br />jN i c 1-) <br />FACILITY NAME La I. t) I 9 0 zr,.c). i_Q_. ry-t <st A.(\ <br />7 . c 3 Street Number Direction <br />SITE ADDRESS <br /> CW \-\---0 \i` (0( Street Name CciP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />STATE ZIP <br />GlY 1 9 SerA1 0. Q: c c IA cIS t / <br />PHONE #1 EXT. <br />PO4 59L1 -D ( <br /> APN # LAND USE APPLICATION # <br />PHONE #2 #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />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 • EDERAL laws. <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 />_ . .• •witamlIM i <br />TYPE OF SERVICE REQUESTED: 140(0 ; ..€ '---oc,c( C.0 ns(.0 fccfior RECEIVED <br />COMMENTS: <br />NOV 1 4 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: co A yx.e_ 6.4 EMPLOYEE #: DATE: <br />ASSIGNED TO: L9 6 0, E, , EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 b( PIE: yo(p5 <br />Fee Amount: (02_ 00 Amount Paid 4,4 7, 2 -- Payment Date ij i / (2t)2 <br />Payment Type ( Invoice # Check # Received By: <br />EHE 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />03/22/23 <br />Po sq0611L-1