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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />IVA)LYl <br />PON <br />C,bO K <br />FACILITY ID # <br />SERVICE REQUEST # <br />SPO SZP 313 <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME L <br />,417-G <br />*f";f <br />SITE ADDRESS <br />'7305,6'tStreet Numbe <br />Direction <br />sSRI <br />yCWSl N <br />G- <br />�/` <br />2dCa'3 <br />HOME or MAIL NG ADDRESS (if Different from Site Address) <br />R JJe!57K Street Number <br />ao—S+p �lCrt <br />eName <br />CITYQ�S ' J, <br />T v <br />C 01,STATE ZIP <br />PHONE #1 5710 ExT <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR L, v ` 5 JE S144 V5'.'fir+n �, CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />IVA)LYl <br />PON <br />C,bO K <br />HOME Or MAILING ADDRESS <br />FA%# <br />( ) <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 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 anre work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, Sr and FEE laws. <br />APPLICANT'S SIGNATURE: r DATE: / lJ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER❑ OTHER AUTHORIZED AGENT 13 <br />IfAPPLLCANT is not the BLLLhVGPARTP proof of authorization to sign is repaired Title <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 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: <br />d (, OY L <br />PAYMENT <br />U V I <br />COMMENTS: <br />JAN 3 6 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #:�a�U� <br />DATE:I 3U Z3 <br />ASSIGNEDTO:LAIL GI � <br />EMPLOYEE#: / 9' <br />DATE: l 30 <br />Date Service Completed (if already completed): <br />SERVICE CODE: /1 <br />PIE: U 2 <br />Fee Amount: t; tf' <br />Amount Paid <br />>I{ �S�p _ <br />Payment Date <br />Payment Type V(S <br />Invoice# <br />I C c # /S 3 1 <br />Received By:lyw� <br />EHO 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />