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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SC-oogl�?,11 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 'blrtaAvarC rrCS <br /> FACT HY NAME Ch e. <br /> S fl ll <br /> SITEADDRESS 1 I S S+OCkto✓V <br /> ITO Streat Number Direction UVlto Yt "� Street Name city21 Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> U Grewsipofo Street Number Street Name <br /> CITY STATE Zip <br /> 9 <br /> PHONE#t Ems• APN# LAND USE APPLICATION# <br /> Qucl ) VZo-3ggL <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> eZ — <br /> BUSINESS NAME PHONE# <br /> IkC os hurl) ( <br /> HOME or MAILING ADDRESSFAX# <br /> q(7'7-(,p 6�rfekldocao UffkiLj <br /> CITY V- - STATE ZIP 9s2 G. <br /> BILLING ACKNOWLEDGEMENT: 1, 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 andFEDERAL laws. <br /> APPLICANT'S SIGNATURE: .L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN. GER ❑ OTHER AUTHORIZED AGENT❑ <br /> !f APPLICANT is not the BILLING 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at[IiG fa[4S.)7me�LLis <br /> provided to me or my representative. �+/{T mCry ' <br /> TYPE OF SERVICE REQUESTED: RECEI <br /> COMMENTS: (` JAN 3 0 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BV <br /> EMPLOYEE I�U b DATE: ( 3U72-3 <br /> ASSIGNED TO: t '(A I., n EMPLOYEE#: �7 DATE: I -3UZ <br /> Date Service Completed (if already completed}: SERVICE CODE: 0 PIE: I &o Z <br /> Fee Amount: I SIC Amaunt Paid Payment Date 1 313 A-e 2 2) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/7712003 <br /> V -0 "IIr) 3 67 <br />