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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F40mm 2- S9-mm8-+2 ks <br /> OWNER/OPERATOR <br /> iVy CHECK If BILLING ADDRESS <br /> J <br /> FACILITY NAME N T r� <br /> I ►rf1 IFA � o�^� � � <br /> SI ADDRESS PjfiG I� c A, V i 0 CV,-1�A.1 �'fS Z0 <br /> 7 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 )3 <br /> Street Number Street Name <br /> CITY STATE ATE <br /> i <br /> G�rt�� C1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME (� I L—A" ^ Q v\� P►fQZ / �3 Ext. <br /> HOME or MAILING ADDRESS I ; �1 A C �n r_ t p FAx# ) <br /> CITY , C I`1 / STATE ZIP ��Z . L EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and tiel}af�TlveFk oo be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT�Ikl',d F DEFj L laws. <br /> APPLICANT'S SIGNATURE: ' DATE: Z <br /> PROPERTY/BUSINESS OWNER❑ OP NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site <br /> address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pro vi to me or my <br /> representative. r\ �'/� <br /> TYPE OF SERVICE REQUESTED: C h Q1;1 e C �Ct x(leV'j�1 �� <br /> COMMENTS: £►p 2J-OAO <br /> QWN <br /> �23 <br /> gMgC <br /> "'P <br /> tel' <br /> ACCEPTED BY:-16y'tM, EMPLOYEE#: DATE: G`2mIZm23 <br /> ASSIGNED TO: t6. EMPLOYEE#: DATE: CJ t 2(b 0Z?j <br /> Date Service Completed (if already completed): SERVICE CODE:CD(1 PIE: <br /> Fee Amount:$*'2- (2Xp Amount Paid �r Payment Date <br /> Payment Type Invoice# # 1 ri 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />