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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5Roa ?--79 5 -� <br /> 7Ctr OWNER IOPERATOR U i�— U 1LE3 CHECK IfBILLINCrADDRESS❑ <br /> FACILITY NAME <br /> IYucl[ �/ p <br /> Com►n. SITE ADDRESS f�l rr\r�t1�p 5 1-0c l co, <br /> Street Number Direction Street Name CityZcTp <br /> / HOME or MAILING ADDRESS (If Different from Site Address) <br /> Mtx�l; :� 9I V S- r " d C <br /> Horne Straot Number Street Namo <br /> CITY -5 -�-O�1`' �� STATE Z1P <br /> \ 1 <br /> PHONE#1 ExT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL SOS DISTRICT LOCATION CODE <br /> CONTRACrI,OR / SERVICE REQUESTOR <br /> REQUESTOR 5 GZ-xYLc 0..5 Pr Ia OV e- CHECK If BILLING ADDRFSSC�_ <br /> BUSINESS NAME O r� � PHONE# Ext. <br /> � c <br /> HOME Or MAILING ADDRESS FAx# <br /> f ) <br /> CITY STATE ZIP EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that atl 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 /> 1 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 /> 4( APPLICANT'S SIGNATURE: icc'- Q\JACS . DATE: <br /> PROPERTY I BUSINESS OWNER Ck OPERATOR I 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 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 JOAOUIN COUNTY ENVIRCNMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It IS provided to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: cUYI u I�a IOt'1` QLA-0 O W i R <br /> COMMENTS: <br /> APR z z 2024 <br /> NVfROUlN Co <br /> 11" 1 <br /> N 4 <br /> Lf�1 DEPART BEN, j <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: F. P, EMPLOYEE#: DATE: 4^ a a - a4 <br /> Date Service Completed (if already completed): SERVICE CODE: O U } P 1 E: I Y <br /> !� vti <br /> Fee Amount: � i(oa Amount Paid I y Payment Date 2 2 12y- <br /> Payment Type Invoice # I # Received By: <br /> EHD 48-02-025 0� SR FORM(Golden Rod) <br /> 03/22/23 �J <br />