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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��CtiS 'tvLli�1�lM i h �tit>4►�I- Y -� SC1 �- <br /> OWNER/OPERAT0567^I1 �l 1e v,A^ _�� �t 0�3" 7 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ^ I Q n V 4 1/� v 1 <br /> SITE ADDRESS 76'") ' vl Lje' � L4 1N <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (l0) <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /(I'Y V/1Y2 L C) �-7 [j� ,n im Dr <br /> (/ (/ � CHECK If BILLIN�G/ADDRESS <br /> BUSINESS NAME n r r PL/ q 1 ,�).e I S PHONE2�# /L�� 3 �)DS E'er <br /> HOME or MAILING ADDRESS �J L' I `/ FAX# (� <br /> CITY /�` STATE ZIP /lt ( �,r}(I EMAIL114 7(�' 21�1 '] S (�✓� ft!l` ��� <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 or activity <br /> will be billed to me or my business as identified on this rm. <br /> also certify that I have prepared this applica i. nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA nd FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: L1( 6h 7 <br /> PROPERTY/BUSINESS OWNER� OPERATOR/MANAGER ❑ 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�l��iQ�j d,ta-me or my <br /> representative. �+//�yTT mm ryryT <br /> TYPE OF SERVICE REQUESTED: jh V!!7 v t 'I��ZL /� �Lt <br /> KLICLIVED <br /> COMMENTS: APR a 6 2623 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: < EMPLOYEE#: i DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 7 7 <br /> Date Service Completed (if already com eted): SERVICE CODE: P <br /> v <br /> Fee Amount: " Amount Paid 1✓�J _ Payment Dae W � a� <br /> Payment Type 1 c� Invoice# Cl e�c{"c# p 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />