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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of BU iness or Properly FACIIJTY ID# SERVICE REgUEST# <br /> T(Aue(\ sake Ott 23�`� � �SG� 1 <br /> OWNER[OPERAT R ^� (n� CHECK H BILLING ADDRESSIBI <br /> Fm:iurr WE T t <br /> 0,\\etR55 <br /> SREADDRESSn <br /> `} C��c 'c c Ave G�c� e t'1 <br /> Strwl Numpr DIrtNRn SaeM ZI CoOa <br /> HOME or MAILING Mamas (if Difound tram Site Address)U <br /> 1SI� (AJ '1\6/ CNN 1L�4 U\\2��� �sxH Cv� <br /> CITY STATE ZIP <br /> PHo eltl CA APN# LAUD USE APPLICATION l� <br /> 12x1) tog-s�r30\ <br /> Pnomi#I EAr. BIDS DISTRICT [LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR I n13 <br /> CHECK H BIWM6 ADDRESS <br /> BUSINESS NAME - PHONE# E0' <br /> HOME or MAILING ADDRESS FM# <br /> 1 ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned properly or business owner,operator or authorized agent of same, <br /> aclmowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity 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 ULe work to be performed will be done in accordance with all SAN JOAQLRN <br /> CouN TY Ordinance Codes,Standards,STADEAo Fell laws. <br /> APPLICANT'S SIGNATURE: z DATE: I'L-r6�22 <br /> T <br /> PROPERTY/BUsuHEssO OPERATOR/MANAGER I] OTuFa AuruomzeDAGe(3 <br /> 1fAPPUCI Ot the BILLING PARTY proof of aurhorizotion to sign is required rill, <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenteUsite assessment <br /> inforrinuion to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTtl DEPARTMENT DS soon ES it is available and at the same time it is <br /> provided to me or my representative. <br /> ENT' <br /> TYPE OF SERVICE REQUESTED: RECE IVED <br /> COMM: MAR 2 9 2022 <br /> SAN JOAOq IN COUNTY <br /> ENWRO MENTAL <br /> HEALTH. IMNIMENT <br /> ACCEPTED BY: rr V'A.e<�C O EMPLOYEE#: DATE: Z- _- <br /> ASSIGNED TO: {�yu'�p` EMPLOYEE#: DATE: 2 <br /> Date Service Completed (Heiready completed): SERVICE 001 11 P)E: d'Z <br /> I"Amount $� i Amount Paid Payment Date 3M >V Z <br /> PaymerdType V Invol"It k#I q1 3 Received By: <br /> EHD 48-02-025 3 1 //(J / L SR FORM(Golden Rod) <br /> REVISED 11/772003 <br /> V f-K 6-K <br />