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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type o pusiness or Property <br />sl---44 ( rt,tek- <br />FACILITY ID # <br />2 <br />SERVICE REQUEST # <br />OWNER/OPERATOR , <br />J 76 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME --7 ,--c4S r / c ' ) ' <br />SITE ADDRESS I ( a 5- s S - <br />U)C.>gtreet Number Direction <br />/1 ir r or we- y <br />' Street Name ' <br />"ttrti-(r) <br />City <br />ica0 C , <br />Zip Code <br />HomA or AllAilLING ADDRESS (If Diprent frorn Site Address) <br />C4-4- Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR — ) <br />----Cj .(-- <br />I <br />&If- —5 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 7—R.L., (2 (6 0 J i 1 /- I PH Wit <br />(e( ) <br />HOME Or MAILINeD7SS (A) / i 1„„Ar 7, , FAX # ( ) <br />CITY e--p:„. t_e/fm STATE (4: A <br />ZIP 9 c•--- 3 M e_eitrici:bry..5 ‘efi/aq) <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sa , <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 />COUNTY Ordinance Codes, Standards, STA FE ERA laws. <br />./I3:r 0 <br />APPLICANT'S SIGNATURE: DATE: d--- <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 to me Of my <br />representative. <br />P y <br />TYPE OF SERVICE REQUESTED: (--------0 0ci 7-7-7/ 7e-- ip•e r ri A. I- ir/7 ) <br />COMMENTS: 1 <br />r Dat <br />0 0 1 2n1 <br />‘v.C4 SAN dal ..... u <br />yetiV,WRPIAlkAli COUnpv. ilyo.p 47AL . t <br />AR rA,fzivr <br />ACCEPTED BY: C EMPLOYEE #: DATE: 02 -1 ,...6\4_1 <br />ASSIGNED TO : <br />eT:7-4tAfrk/"1 <br />EMPLOYEE #: DATE: e9-- - ( -) r14 <br />Date Service Completed (if alre(ady completed): SERVICE CODE: ("' ( PIE: /063 <br />Fee Amount: e,2 Amount Paid t { (12Q . Payment Date <br />Payment TypeII/ C4,2 Invoice # Check # / 003 Received By: <br />I also certify that I have prepared this applica rn that the work be performed will be done in accordance with all SAN QUIN J7 <br />(Off <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />Po c1 (At- 0