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Pca � o .� <br /> SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT <br /> SEILVICE REQUEST <br /> Type of Business or Property FACILITY 11) # SERVICE REQUEST # <br /> Me-a) or.) � SpC�CD �,� ssl <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS0, 61 t �- / V <br /> , * <br /> �] L <br /> StrootNumbor D�tlon J6�J, <br /> � � � � "g{�et a �? '" � t zl Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Numbor Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN # LAND USE APPLICATION# <br /> � 1) ko B <br /> PHONE#2 ExT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME '�// PHONE# ExT. <br /> HE or MAILING A DRES 1 FAX# <br /> Y <br /> CITY STATE ZIP <br /> BILLING ACHNOWLI;DGEiMENT: I, the undersigned property or business owner, operator or authorized agent of sarne, <br /> acknowledge that all site and/or project specific ENVIRONMEN'I'AL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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, Standar ATE and I Ev laws. <br /> APPLICANT'S SIGNATURE: � � DATE; 1 0 fJF� <br /> I <br /> PROPERTY/ RUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIJFR AUTHORIZED AGENT� �� <br /> If APPLicA1VT is not the BILLINGYARTY,proof of authorization to sigh 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 EENVIRONMENTAL HEAL'CH DEPARTMENT as soon as it is available and at the i time it is <br /> provided to Ine or my representative. <br /> I" y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DC^ D <br /> C('• 1 <br /> SAN ,0 2023 <br /> NFgc�V/0)p p�6A/ UN y <br /> RTMEN <br /> ACCEPTED BY: EMPLOYEE#: r DATE: <br /> 0b t / '_.'' <br /> ASSIGNED TO; EMPLOYEE#: ., r t DATE: <br /> ) <br /> Date Service Completed (if already completed): SERVICE CODE: P!E: �. . <br /> i , <br /> Fee Amount: 4. t Amount Paid 11 14 2 Payment Data <br /> payment Type vl Invoice # Check # I? 3 Gd Z) Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />