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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R008CoO50 <br /> OWNER i O RATOR <br /> \r CHECK If BILLING ADDRESS <br /> FACILITY NAME �/ VO\ <br /> SITE ADDRESS ,Q�O S�dv�'cc�A\ 4 c S�oc ,}oYl c%wro <br /> uStreet Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• T APN# LAND USE APPLICATION# <br /> (10q) oo <br /> PHONE#2 EXT. BOS DISTRICT CODE[LOCATION <br /> yglrJbJPO;Ef <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site ancUor project specific ENVIRONMENTAL HEALTH DI.P,ARTMENT 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 /> COLNTY Ordincuace Coder,Standczr'd , . A _and F ERM laws. f <br /> APPLICANT'S SIGNATURE: DATE' 1� I,O ! a•Oaa <br /> PROPERTY/BuslNF:ss OWNER P A"I' R/�'IANACF.R ❑ OTIIF"R ACTT ORIZED AGENT P��e�� �'lanaa2r <br /> I/APPLICANT is not the BILLING PART}',proof'of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: 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 environmental/site assessment <br /> inforniation to 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. <br /> TYPE OF SERVICE REQUESTED: PAY <br /> -v' <br /> COMMENTS: <br /> 'V'O V 5 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Za Saeed EMPLOYEE#' DATE: <br /> ASSIGNED TO: HazaSaeed EMPLOYEE#: DATE: 11/10/22 <br /> Date Service Completed (if already completed): SERVICE CODE: O P I E-79 0 a <br /> Fee Amount: $156 Amount Paid 6 S _ Payment Date Ll 2-2 <br /> Payment Type Invoice# 610 7 1 Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />