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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />i--AM82-4 -1- <br />SERVICE REQUEST # <br />SiRcbcD8-4-1S‘ <br />OWNER / OPERATOR <br />--CHECK if BILLING ADDRESS <br />ikii ND €-, F w of A , Ti>1 <br />FACILITY NAME <br />' 1-)C-: L- ) Cl H T -EA) D/ A Ai tin ..Pie, 6i.t: C U I _..c 1 NE <br />SITE ADDRESS <br />/ 1 (/ C Street Number Direction <br />V‘) (c) L (7 ) 1 4]) 4-1) 0 <br />Street Name <br />/21 70A) <br />City <br />i9 C 336 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />I 7 Ci-i C/C)STMAK) C I Street Number Street Name <br />CITY STATE ZIP <br />II i IL) go P CA 9 C 3 3 0 <br />PHONE #1 ecr. <br />(S-10 ) 6 IC Lig 19 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(S (C/ ) -7 -?) / g3sq EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <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 />will be billed to me or my business as identified on this form. <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <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. kt, <br />APPLICANT'S SIGNATURE: <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 PROPERTY/BUSINESS OWNER, OPERATOR <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title 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 in <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi <br />representative. <br />CL1 <br />TYPE OF SERVICE REQUESTED: CY-1CAS1 e oc Ow ne_Ar StnAp S'Ep n r. <br />v u ' COMMENTS: 2023 SAN <br />NEZIWRO/C%,ti: C°U/Vry TH DEp EN TAL <br />AiR NEN 1.. <br />-0 <br />ACCEPTED BY: _ANA__ tk.k.„ EMPLOYEE #: DATE: q V„, \ -2.,2) 2...3 <br />ASSIGNED TO: GI .e.R.r.A ....m.C, F. EMPLOYEE #: DATE: CO (s, \ 2.0 2.3 <br />Date Service Completed (if already completed): SERVICE CODE: PIE:00 0?_ <br />Fee Amount: 4, ‘ ,20(J Amount Paid i cQn . Payment Date <br />Payment Type 6.akci Invoice # 43c4ty,#: (62 047-1/1!,Lp Received By: aAre-d-' <br />DATE: q // <br /> <br />Wi to the z <br />a.; t :. • <br />END 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />'?i2os24,A-7-ei