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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PC few,1 su ft' 5 SV-T@SGgC1S <br /> OWNER I OPERATOR <br /> jof G f I 4 C/-n J ^G CHECK if BILLING AnDRESs� <br /> FACILITY NAME .01 <br /> �©to la""' <br /> t. <br /> SITE ADDRESS - S f 15 i �J�Z L J <br /> _ <br /> Street Number Direction Street Name city ZIp Code <br /> }TOME or MAILING ADDRESS (If Different from Site Address) -71 Z o n sof, <br /> Street Number OtIUVI <br /> CITY 0 d+ STATE A ZIP �S L 4 LD <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# 7 <br /> ('I-'q) 663 - 6 Y'7y <br /> PHONE#2 EXT. EMAIL SOS DISTRICT LOCATION CODE <br /> aoch -7 -f{F, :ll cu DM r Z J t6o noL) I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR R <br /> +�I `('1 G CHECK if BILLING ADDRESS <br /> BUSINESS NAME n s I� / PHONE � 7 E�rT• <br /> (3�e 1, a►n cr (�c.r C.� b <br /> HOME or MAILING ADDRESS 1 �� O( FAX# <br /> CITY STATE ZIP /j�S ZLl EMAIL <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 FEOE AL laws, <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I13USINESS OWNER❑ 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is provided t�rle or my <br /> representative. VA <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS! ✓�/ ( <br /> �1 <br /> N E'wi�. ?023 <br /> ACCEPTED B EMPLOYEE#: DATE: 2-6 .�12 <br /> ASSIGNED TO: \f EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: z PIE: + k1I <br /> Fee Amount: (:� Amount Paid Payment Date /Z- l <br /> Payment Type Invoice# ` Received Sy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03122/23 <br /> W2qao <br />