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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> few sem° <br /> E�� 0 20I a <br /> OWNER/OPERATOR T^ „ <br /> ( )'` CHECK If BILLING ADDRESS <br /> FACILITY NAME T�a <br /> SITE ADDRESS I Z ( I 'u(� ,A, S Vt7.t. (,0 5� 't;,Street Num <br /> bar Direction Street Name Clt Zip Code <br /> HOME or MAILG 711 ifferent fromSite Address) <br /> Z W <br /> Street Number pA Street Name <br /> CITY TE <br /> ,1,�„�7-6 If 14 1�2�5 <br /> PHONE#1 �r' Ems• APN# LAND USE APPLICATION# <br /> ( ZOJ - 296r - 666 <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( Dx I - (�/;'- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> {{��T �a,J� CHECK if BILLING ADDRESS <br /> BUSINESS NAME 't—IA Te� PHONE# Ems' <br /> t� 1 ( <br /> HOME or MAILING ADDRESS Z 7 / t'11 V i-Lao K ✓/ FAX# <br /> p J kJ "/� "'LLL J/ W ( ) <br /> CITY As� STATE CA ZIP <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,STATE and F RALJaws <br /> APPLICANT'S SIGNATURE: DATE: d Z I J 7,9� 7- <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required T rte <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 environmental/site assessment <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the same time it Is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: COn u fA_- On KEICEIVED <br /> COMMENTS: SEP 21 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: JZ t <br /> ASSIGNED TO: /` EMPLOYEE#: _7Q g DATE: <br /> Date Service Completed (if ahead completed): SERVICE CODE: 0(01 PIE: CY�� <br /> Fee Amount: 1 5(p 1 <br /> Amount Paid /5�' Payment Date Z/ �ZZ <br /> Payment Type V I S A Invoice# ChL—ck# l b b S Received By: AfIr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> eg.053 S <br />