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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3kDM;9gL4 <br /> OWNER I OPERATOR I <br /> {l� CHECK If BILLING ADDRESS <br /> FACILITY NAME. 1 <br /> SITE ADDRESS /t` C, <br /> 2 5 reel NI tuber Dlr'ctnon a C �i�� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) v <br /> OStreet Number beet Name <br /> CITY )i"A E ZIP '5_2 4 2- <br /> PHONE#t Ex. APN# `LAND USE APPLICATION# <br /> ('Lal) lP�� ' �Gl <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR <br /> ljt CHECK It BILLING ADORES <br /> BUSINESS NAME l�l I PHONE# ,, ff Exr• <br /> 1 'I G <br /> HOME Or MAILING ADQRESSFAx# <br /> I b 1 rL oc� ( ) <br /> Cm I STAT ZIP 5Z4 2— <br /> BILLING <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•, T�and FEDERAL laws. 2--2— <br /> PROPERTY/ <br /> l <br /> APPLICANT'S SIGNATURE: ,Q P Ll ��,�y I/� DATE: 11 / !-� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to sign is required Thie <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 environmental/site assessment <br /> Information 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. , / r,, p <br /> TYPE OF SERVICE REQUESTED: �D V�jy (�l.S L �MIr <br /> COMMENTS: tIV�D <br /> Nov 03 2022 3 ?D?? <br /> c <br /> �N JOAQU/ <br /> M E�Rp ON N CDrUN <br /> �CllipgFN1Y <br /> ACCEPTED BY: C EMPLOYEE DATE: IIS <br /> ASSIGNEDTO: Cln EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: (fit //f PIE: <br /> Fee Amount: I _ Amount Paid 15� U Payment Date 1 3 ZZ <br /> Payment Type . Invoice# Check# ISa 3( 2 I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod). <br /> REVISED 11/17/2003 <br />