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EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />PP21400858 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />PA CHECK if BILLING ADDRESS 1:414(.01 tilt :it/1V) <br />Faciury NAME <br />g-/-7Y) '5 <br />. <br />•:__, <br />SITE ADDRESS „wry - <br />Street Number <br />Ai <br />Direction Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 4itoy <br />' Street Number or6' ' Y f-tligelelittir WAY <br />Street Name . c <br />ITY flIt''' 476 i <br />STATE ZIP eAt en-t;ii sg-- <br />PHONE #1 - Ext. <br />Inv) <br />APN# LAND USE APPLICATION # <br />PHONE #2 ., EXT. <br />ritilt) Foke '' 70247 <br />EMAIL, <br />,,_:)„:,,t 7;-.-,,,,;,.,_,,, s,(:-, i BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REOUESTOR <br />1P-7 <br />. _ <br />CHECK if BILLING ADDRESS El -1/6 <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAIUNG ADDRESS ' Fax # <br />( 1 <br />CrrY 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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: i. DATE: o-Ki <br />PROPERTY / BUSINESS OWNER Et OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: CC4Ji eAr.irt 9 Con j;,,,',114 -le 0 PAYMENT <br />COMMENTS: RECEIVED <br />FEB 2 <br />SAN JOAQUIN <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />9 2024 <br />COUNTY <br />DATE: 1. i2rit i a 4.4 ACCEPTED BY: -3e. c c (.--..._. EMPLOYEE #: <br />ASSIGNED TO: ,. : C... EMPLOYEE #: <br />Date Service Completed (if already completed): SERVICE CODE: ,L,..-(... PIE:IiL,C49 2 <br />Fee Amount: IAL-/2_ •(2 a Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />Title