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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE# ExT. <br />r <br />�1 -UOQ <br />OWNER / OPERATOR <br />�. CJ <br />CHECK If BILLING ADDRESS� <br />0� I <br />( ) <br />FACILITY NAME <br />LA Con I,4A p4—;z <br />A4C Imo- (LA COLrI MA « 141a6Cz4CH <br />SITE ADDRESS <br />I <br />xff�tf W <br />EMPLOYEE <br />DATE: 3--�—z-- <br />Street Number <br />Direction <br />EMPLOYEE#: <br />Street Name <br />Cil <br />ZI Code <br />HOME Or MAILING ADDRESS (If D'fferen't' f''ro''mII Site Address) <br />SERVICE CODE: y' <br />PIE: i;'D ( <br />15 goo S iZr�v t D � <br />1 <br />\ Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />1 <br />1 'r"r <br />Q <br />PHONE 911 Ezr. <br />APN# <br />LAND USE APPLICATION# <br />WS) 337- G3Z2 <br />PHONE#2 EXr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />[J CHECK If BILLING ADDRESSED <br />r <br />BUSIN�SSNAME <br />PHONE# ExT. <br />�c �1 1 aL 4- <br />3 _ <br />HOME or MAILING ADDRESS <br />FAX # <br />!S <br />k <br />( ) <br />CITY I M 1 0 P:;,r- TATE ZIP C/1S3sgf) <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 <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAAE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: /l DATE: + 2 <br />PROPERTY/ BUSINESS OWNER❑ Olta=/MANAGER❑ OTHER AUTHORIZED AGENT <br />IfAPPLicANT is not the BmLmG PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 enviromt ntDust te assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available antime it is <br />provided to me or my representative. N70 <br />TYPE OF SERVICE REQUESTED: Q"w <br />4( c <br />AdAQ <br />COMMENTS: <br />_amAR'-'QUIN 2022 <br />N CU Nne <br />H 7XtDEPAR <br />AI <br />M At <br />NT <br />ACCEPTED BY: <br />xff�tf W <br />EMPLOYEE <br />DATE: 3--�—z-- <br />ASSIGNEDTO: <br />140� L -1K ka'�P/}. <br />EMPLOYEE#: <br />DATE: n -?_22_ <br />7 - <br />Date Service Completed (if already completed): <br />SERVICE CODE: y' <br />PIE: i;'D ( <br />Fee Amount: <br />✓� �' <br />r <br />Amount PaidG7., <br />t-- <br />Payment Date 2� <br />Payment Type <br />Invoice #�"T <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />P P 0ts-q-7 SVI <br />SR FORM (Golden Rod) <br />I <br />